Initial Psychiatry Consultation Template

Main Complaint:  
The patient, a 35-year-old male, presents with ongoing feelings of sadness and hopelessness for the past six months, significantly affecting his daily activities and work performance.
Symptoms:  
The patient reports experiencing low energy, difficulty concentrating, and a lack of interest in activities he once enjoyed. These symptoms are present daily and are severe.
Other symptoms:  
The patient also mentions frequent headaches and insomnia, which have worsened his condition.
Stressors:  
The patient recently underwent a divorce and is experiencing financial difficulties, contributing to his current mental health status.
Past Psychiatric Hx:  
The patient has a history of depression diagnosed five years ago, treated with cognitive behavioral therapy and medication, with partial improvement.
Past Medical Hx:  
The patient has a history of hypertension, managed with medication, and no significant surgical history.
Trauma Hx:  
The patient reports experiencing emotional abuse during childhood, which has had a lasting impact on his mental health.
Habits:  
The patient smokes half a pack of cigarettes daily, consumes alcohol socially, and leads a sedentary lifestyle with irregular sleep patterns.
Childhood:  
The patient grew up in a single-parent household with strained family dynamics and limited social support.
Education:  
The patient completed a bachelor's degree in business administration but struggled with concentration during his studies.
Work Hx:  
The patient is currently employed as a sales manager but reports high levels of job-related stress and dissatisfaction.
Personal Hx:  
The patient has limited social interactions and relies on a small circle of friends for support.
MSE:  
Appearance: The patient appears disheveled, with unkempt hair and casual clothing.  
Behaviour: The patient is cooperative but appears withdrawn during the consultation.  
Speech: The patient's speech is slow and monotonous.  
Eye Contact: The patient maintains minimal eye contact, often looking down.  
Concentration: The patient demonstrates difficulty maintaining focus during the session.  
Attention: The patient's attention span is limited, frequently losing track of the conversation.  
Mood: The patient reports feeling "down" and "empty."  
Affect: The patient's affect is flat and incongruent with the content of the discussion.  
Thought form: The patient's thought process is coherent but slow.  
Thought Content: The patient denies any delusions or obsessions but expresses feelings of worthlessness.  
Perceptual Disturbances: The patient denies any hallucinations or illusions.  
Suicidal Ideation: The patient admits to having passive suicidal thoughts but denies any plans or attempts.  
Insight: The patient demonstrates partial insight into his condition, acknowledging the need for help.  
Judgement: The patient's judgement appears impaired, as evidenced by poor decision-making in personal matters.  
Intelligence: The patient's intelligence is estimated to be average based on his educational background and work history.  
Mode of thinking: The patient's thinking is predominantly negative and self-critical.  
Sleep: The patient reports difficulty falling asleep and frequent awakenings throughout the night.  
Appetite: The patient has experienced a decreased appetite, resulting in weight loss.  
Libido: The patient reports a significant decrease in libido.  
Physical Complaints: The patient reports chronic tension headaches, which he attributes to stress.
Assessment:  
The patient is assessed to have major depressive disorder, with contributing factors including recent life stressors and a history of trauma.
Plan:  
- Initiate treatment with an SSRI (Selective Serotonin Reuptake Inhibitor).  
- Recommend cognitive behavioral therapy sessions.  
- Schedule a follow-up appointment in four weeks to assess progress.  
- Provide information on local support groups for additional social support.