Narrative Intake Summary

Sarah Jenkins, a 34 year old female, presented to the clinic on 14/05/2024 with progressive low mood, anhedonia, terminal insomnia, and a 4 kg weight loss over the past six weeks following a job loss, though she denies any suicidal or homicidal ideation. The patient reports a history of primary hypothyroidism, a single episode of major depressive disorder in 2019, and a laparoscopic appendectomy in 2015.

The patient is currently taking levothyroxine (Synthroid®) 75 mcg PO daily and melatonin 3 mg PO QHS and has a known allergy to penicillin, which causes urticaria.

Social history reveals that the patient lives alone, is currently unemployed, denies tobacco or illicit drug use, and consumes two standard alcoholic drinks per week.

The patient’s family history includes major depressive disorder in her mother and generalized anxiety disorder in her maternal aunt.

The patient’s review of systems is significant for fatigue, decreased appetite, and poor concentration, and is negative for manic symptoms, psychosis, palpitations, or cold intolerance.

The patient’s physical examination findings include a blood pressure of 118/74 mmHg, a heart rate of 68 bpm, a temperature of 36.8 °C, a well-groomed appearance, psychomotor retardation, depressed mood, restricted affect, linear and goal-directed thought processes, and intact cognition, insight, and judgment.

The patient’s diagnostic test results include a PHQ-9 score of 18 indicating moderately severe depression, a GAD-7 score of 6, a normal TSH of 2.1 mIU/L, and an unremarkable complete blood count and comprehensive metabolic panel.

The patient’s treatment plan includes initiating sertraline (Zoloft®) 50 mg PO daily for recurrent major depressive disorder and referring her for weekly cognitive behavioral therapy.

The patient was advised to monitor for any emerging suicidal ideation or activation symptoms, utilize crisis resources if acute distress occurs, and return to the clinic for a follow-up evaluation in four weeks.