Basic Patient Information

Patient Demographics:

Patient Initials            Age: 16           Sex: Female    Marital Status: Single         

Language:                 English            Race: White    Ethnicity: White Americans

Sexual Orientation:   Bisexual          Education: 11Th Grade        

Occupation:   Student

Allergies: No notable allergy  

Pertinent Data About Case

(This includes: Reason for visit; HPI; Past Psych hx; Medications, Social/Environmental factors, co morbid medical conditions, MSE, & Diagnoses) 

Chief Complaint: I am feeling sad and frustrated.


History of Presenting Illness

Mary is a 16-year-old excited teenager in 11th-grade full-time school. She enjoys socializing and extramural activities while in school. Mary was recently diagnosed with diabetes type 1 and recommended insulin pump therapy. Since then, she has withdrawn from the family and no longer play with friends, and she exhibits low self-esteem and hopelessness and even lost interest in activities she enjoyed doing. The GP diagnosed depression. The patient’s condition has been persistent and worsening for two weeks, significantly straining her parents. The GP settled that the patient’s case needed special attention and referred her to Community Mental Health Team.

Past Psychiatric History: No history of psychiatric problem

Medications (current medical & mental health)

Mary’s referral notes indicate that the depression should be examined further because of the patient’s mental health deterioration. The examination underscored significant depression symptoms, including the persistent feeling of sadness, weight loss, poor sleeping patterns, and burdensomeness. Also, loss of pleasure in enjoyable everyday activities, diminished energy, irritable mood, gloomy outlook, and irritable symptoms were contemporary (Kamenov, Caballero, Miret, Leonardi, Sainio, Tobiasz-Adamczyk, & Cabello, 2016). The symptoms are highly likely to affect the patient’s coping ability, personal life, and overall quality of life.

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Psycho-Social/Family History

Relationship Status: Mary is a friend’s daughter. She has a boyfriend, but she still lives with her parents.

Support System: Mary currently confines her elder sister and the father for emotional and social support. She is closer and free with her father than anyone else, and she does not seem interested in talking to anyone when the father is around. But she talks mostly to her elder sister when the father is away. However, since diagnosis, she distanced herself from her mother and brother and often fought them at the slightest provocation.

Housing: Mary presently lives with her parents in a three-bedroomed house in the middle of the upper-income neighborhood.

Education: Mary is a full-time student currently in 11th grade.

Developmental Milestones: Mary is currently in an adolescent stage of development.

Legal: A person

Abuse/Trauma: No history of trauma  

Military Service: No history of military service

Cultural Concerns: She highly values her positive self-image

Other: She is so religious and loves reading the bible.

Relevant Comorbid Medical Problems and Physical Disabilities (example- diabetes, asthma, chronic pain, birth defects, sensory impairment, impaired mobility, and so on)

Mental Status Exam

Appearance: moody and disturbed

Motor Activity:  walks but appears weak

Attitude: she has an aggressive and rebellious attitude

Speech: talks clearly

Affect: negative affect 

Mood: depressed and sad

Thought Processes: exhibits lack of goal-directedness and keep introducing seemingly unrelated thoughts

Thought content: appears preoccupied and obsessed.

Suicidal ideation: no history of suicidal ideation

Homicidal ideation: No history

Cognition: identity confusion andpoor motor coordination

Orientation: is aware of the place and time/alert

Memory: clear memory

Insight: fair, she acknowledges that she feels stressed

Judgment: Synthetic judgments can only give descriptive details on a situation.

Stream of Thought: expresses inability to focus on one thought or idea

Psychomotor Activity: decreased

Fund of Knowledge: aware of social events around her

Cognitive Function Abilities:

Attention spanfour seconds


Abstract thinkinglow

Concrete thinkinghigh

Metaphorsstruggling to defeat depression


(include DSM 5 code and all components of diagnoses)

F32.3_Major depressive disorder, single episode, severe with psychotic characteristics

Interventions (or “medical decision making”)

The most recommended intervention for the patient is a mix of psychotherapy and antidepressant medications. Even though effective psychotherapy and antidepressant treatments have been developed, study shows that only about two-thirds of patients under depression respond to a single-modality treatment (Dunlop, 2016). Hence there is a need to combine both psychotherapy and antidepressant for effective outcomes. As for the antidepressants, the doctor should begin by prescribing SSRI, including escitalopram (Lexapro) and citalopram (Celexa), as they are safe for kids and causes few to no bothersome side effects (Jennings, 2018). SSRI is the best option for the patient as she is currently under other diabetes medications.


Kamenov, K., Caballero, F. F., Miret, M., Leonardi, M., Sainio, P., Tobiasz-Adamczyk, B., & Cabello, M. (2016). Which are the most burdensome functioning areas in depression? A cross-national study. Frontiers in Psychology7, 1342.

Dunlop, B. W. (2016). Evidence-based applications of combination psychotherapy and pharmacotherapy for depression. Focus14(2), 156-173.

Jennings, L. (2018). Antidepressants. In Clinical Psychopharmacology for Neurologists (pp. 45-71). Springer, Cham.