Chief complaint: “I am experiencing depression and have lost interest in all activities.”
HPI: The patient is a 31-year-old female with a medical history of depression and breast cancer. She was diagnosed with breast cancer approximately one year ago and has been undergoing chemotherapy. The patient reports feelings of depression and has fears of dying from cancer, likely influenced by her mother’s previous experience with cancer. The patient is currently using Trazodone 50 mg on an as-needed basis for sleep.
Mental Status Examination: The patient displays disorientation, agitation, and disorganization. She appears guarded and exhibits a flat affect. The patient’s appearance is consistent with her stated age, and she appears well-groomed. She denies any current thoughts of suicide. The patient demonstrates limited insight into her own problems.
Diagnosis: The patient is diagnosed with Major Depressive Disorder according to DSM-5 criteria (296.23, F32.2).
Plan: The patient’s treatment plan includes initiating Wellbutrin XL at a daily dosage of 150 mg to address her depression. She will also continue using Trazodone 50 mg as needed for sleep. The patient is referred for psychotherapy to address her emotional well-being. She is educated about the potential side effects of the prescribed medication, emphasizing the importance of medication compliance and adherence to the treatment plan. The patient expresses receptiveness to the provided information and demonstrates readiness to comply with the proposed treatment plan. A follow-up appointment is scheduled in two weeks to evaluate the progress of the treatment.
