Edited Sample Report

This patient is feeling a bit better. He has some good days, but when he has a bad day he feels quite depressed and suicidal. He cannot see any hope for the future.

Medication
Serzone 250 mg twice a day and clonazepam, 0.25 mg b.i.d. and 0.5 mg q. h.s.

Current Mental State
This patient is pleasant and cooperative. He is alert and responsive. His orientation is full for time, place and person. Mood is still depressed. Affect is flat. Thinking is logical and coherent. Thought content is informative. No obsessions, compulsions or phobias noted. Sleep and appetite are only fair.

Assessment
I think this patient is suffering from a double depression, meaning a major depression superimposed on a dysthymic disorder. As we treat his depression more aggressively, both his conditions should come under control.

Plan
For now, I have advised him to increase the Serzone, 300 mg twice a day. I will continue him at this dosage for the coming three weeks. If his response is not adequate, I will consider augmenting the Serzone with lithium carbonate, 300 mg, two or three times a day. I will review him at my office during the early part of January.

Edited Sample Report

This patient is feeling quite depressed, irritable, sad, and unhappy. He told me that he lost his job as he could not cope with life stresses any more.

This patient has a history of drug substance abuse since age 13. The drug abuse included cocaine, crack, pot, mushrooms, LSD, heroine, and alcohol. According to him, he quit doing drugs about a year ago.

He comes from a disturbed family background. His parents drank to excess. Mother was ** when he was born. His father was ** and they were not quite prepared to handle the responsibilities of a baby. He was brought up by his grandparents. He also has a twin sister.

Through the early part of his life he grew up hating his parents. He used to get into fights quite often. He managed to complete Grade ** education. Subsequent to leaving school, he had difficulty settling down to doing anything in particular. He was involved in a motor vehicle accident in a head-on collision in 1990. Following the accident, he was unconscious for some time. He remained sick for a period of 2½ to 3 years.

This patient also has relationship problems as well as some legal problems.

Medication
Effexor, Zoloft, and Epival.

Current Mental State
This patient is alert and responsive. His orientation is full for time, place and person. His mood is irritable and depressed. Affect is appropriate. Thinking is logical and coherent. Thought content is informative. No hallucinations noted. He did not show any evidence of delusions. His memory is intact for past and recent events. No obsessions, compulsions or phobias noted. Sleep and appetite are fair.

Assessment
Axis I -- Major depression, recurrent. Acute stress disorder secondary to present life situation. Polysubstance abuse disorder in remission. Adult Attention Deficit Hyperactivity Disorder.

Plan
Patient will be seen for further review next week.

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