Subjective:

CC: The patient reports feeling sad and unmotivated.

HPI: J.D. is a 42-year-old male who presents for a follow-up appointment regarding his depression. He has a past psychiatric history of depression and anxiety, for which he has been treated with medication and psychotherapy. He reports that his current medication regimen (fluoxetine 20mg/day) has been somewhat effective in managing his symptoms, but he still feels sad and unmotivated. He reports a lack of interest in his usual hobbies and difficulty concentrating. His symptoms have been present for several months and have not improved despite his medication.

Substance Use History: J.D. reports no history of substance abuse.

Current Medications: Fluoxetine 20mg/day.

Allergies: J.D. reports no known allergies.

Reproductive Hx: Not applicable.

ROS:
General: No weight loss, fever, or chills.
Cardiovascular: No chest pain or palpitations.
Respiratory: No shortness of breath or cough.
Gastrointestinal: No nausea, vomiting, or diarrhea.
Musculoskeletal: No joint pain or stiffness.
Neurological: Reports difficulty concentrating and feeling unmotivated.
Psychiatric: Reports feelings of sadness and lack of interest in hobbies.
Endocrine: No history of diabetes or thyroid disease.
Skin: No rashes or lesions.

Objective:

Vital signs: Blood pressure 120/80 mmHg, heart rate 72 beats per minute, respiratory rate 16 breaths per minute, temperature 98.6°F.

Physical exam: The patient appears sad and lethargic. He demonstrates poor eye contact and a flat affect. No abnormal findings on physical exam.

Assessment:

Mental status exam: The patient appears sad and lethargic. He has a flat affect and poor eye contact. He reports feeling unmotivated and having difficulty concentrating. His mood is depressed and his affect is congruent with his mood. He denies suicidal or homicidal ideation.

Differential diagnosis:

Major depressive disorder
Dysthymic disorder
Adjustment disorder with depressed mood
Plan:

Increase fluoxetine to 40mg/day and re-evaluate in 4 weeks.
Recommend psychotherapy to address depressive symptoms.
Provide patient with resources for support groups and crisis hotlines.
Schedule follow-up appointment in 4 weeks.
Reflection:

In this case, J.D. presents with symptoms of depression despite being on medication. As a provider, it is important to recognize that medication alone may not be sufficient to manage depressive symptoms and that psychotherapy may be a helpful adjunct treatment. It is also important to assess for suicidal or homicidal ideation and provide appropriate resources for support. Finally, it is important to schedule follow-up appointments to monitor the patient’s progress and adjust treatment as needed.

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