NAME: Smith, John

John Smith, MD, a 45 year old MWM presented with concerns about depression. Pt presented in NAD for his scheduled appointment. Pt reported that he has "been feeling blue for a few months now and [his] wife really thought [he] should speak with someone." Pt initially minimized his emotional experience reported that he was simply "blue" and "melancholic" but later reported that he had early morning awakenings, impaired concentration, increased alcohol consumption, and suicidal ideations. No collateral information was obtained from outside sources, but Pt appeared to be a reliable historian.

Pt reported that about 5 months ago he was promoted from Asst to Assoc Prof, and with the promotion came additional demands on his time. Around the same time he and his family moved. He subsequently noticed increased fatigued but attributed this to work and the move. Over the past few months he has felt increasingly worse physically and emotionally, and has contemplated death for the first time.

Pt was treated for depression during his first year of med school after moving to Boston at which time he felt overwhelmed. He sought counseling though his university Counseling Center, and saw a psychiatry resident for about 6 months, and was on a TCA for about a year. Treatment was deemed successful and satisfactory as the depression fully resolved. He denied psychiatric hospitalization.

Pt reported he typically drinks a glass of wine with dinner every other night or so, and he will drink up to three cocktails at parties. Since feeling depressed, he has decided to temporarily stop drinking and thus has not consumed alcohol for a couple months. In college he experimented with marijuana, but denied this his use was problematic. He occasionally smokes cigars and typically consumes 2-4 caffeinated beverages per day. He has never required substance abuse treatment.

Pt's parents are alive and well, and they remain married to each other. His entire family of origin remains in the mid-west where he grew up. Father, 72, is a retired factory worker. Mother, 68, is a part-time medical secretary. Pt is close with his parents, and speaks with them twice weekly. Pt is the youngest in a sibship of three. His 48 year old brother is an auto mechanic but is currently "between jobs" and in the process a divorce. His 46 year old sister is a nurse and is married with two children. Pt is closer with his sister than his brother. Sister was treated for depression/anxiety a few years ago, and was prescribed an SSRI. Pt has been married for 17 years, and describes his relationship as supportive, though not very affectionate or intimate. He and his wife typically have sexual relations once or twice a month, and though this has been unsatisfying to him, the couple has done nothing to change. They have two daughters, ages 15 and 13, and both are doing well in private school.

Pt denied history of developmental problems, abuse/neglect in the family home, or antisocial behaviors as a child, adolescent, or adult. Pt completed his residency in IM after which he accepted a faculty appointment at JHU. He was recently promoted from Asst to Assoc Prof, and enjoys his work, though he works longer hours than ever anticipated, and feels overwhelmed by excessive demands on his time.

Pt has a strong and supportive support system comprised of immediate and extended family and friends. In the home are Pt, his wife, and their two daughters. Daughter had a school friend stay in the home for about a month until last week while friend's mother was in treatment for alcoholism. Pt denied a history of arrests or other legal problems. Pt owns a .38 special revolver, which he uses for target practice, and stores in a lock box in the basement with ammunition stored separately. He denied financial strain.

Pt has not had a physical in years and does not have a regular PCP. He self-medicates minor colds or flues. Most recent blood work was about 3-4 years ago. Pt takes Flonase, prn, for chronic/recurrent sinusitis, and a daily multi-vitamin. Pt reported fine health other than sinusitis and recent complaints of fatigue. He denied history of major illness or disease, though he reported he was involved in an MVA 8 years ago in which he lost consciousness for about 15 minutes and sustained a concussion. F/U head CT several weeks later was normal. Pt denied history of surgery and reported NKDA.

On exam, Pt was A&Ox3. Speech was a bit slowed. He evidenced no signs of thought disorder or psychosis. Thought process was logical and goal-oriented. Pt reported excessive fatigue and hypersomnia (more than 8-10 hours plus after-work nap, relative to baseline of 6-7 hours) lately. He reported decreased appetite with some weight loss. Pt is slightly slowed motorically. He denied crying spells. Stated mood was "blue and perhaps a bit melancholic". Affect was congruently depressed and relatively narrow in range. He denied history of mania/hypomania. Pt denied SI, plan, intention, or behaviors, but reported PDW (e.g., his family would be better off financially if he just somehow died). However he listed hurting his family as his primary protective factor against SI. He exhibited moderate psychological pain and pressures/stressors, but low agitation. He denied HI. Pt reported moderate anhedonia and though he expressed a future orientation, he reported little hope that he will feel better. Pt reported difficulty with memory, focusing, and sustaining concentrating. Judgement and impulse control are adequate, though he seems to lack insight into his illness.

Initial diagnostic impression is Major depressive disorder, recurrent, moderate (296.32) on Axis I; no diagnosis on Axis II; and chronic recurrent sinusitis on Axis III. Presentation appears to be a reactive (likely in response to his recent promotion and move) and recurrent depression of moderate severity with some PDW and relatively low suicide risk in light of history and protective factors. Of concern is the recurrent nature of his depression, it's severity, access to firearm, and the fact that when energy restores he may become agitated and more at risk for acting upon his PDW/SI. Pt has a stable support system, is high functioning and has multiple protective factors. He has BC/BS insurance. Pt was provided a supportive session, offered bibliotherapy, and referrals for medication evaluation and on-going psychotherapy (Drs Smith, Jones, and Wilson). He was provided emergency contact info and completed a "safety card" (contacting wife, friend, exercise, take nap). RTC 1 week.
 
 

 
FASAP Clinician

This note is purely fictitious and used for training purposes.  Any representation or resemblance to a real person is entirely coincidental.