MDD with seasonal pattern (F33.9)
Criteria Clinical Notes
Subjective CC: “Mom says I get moody this time of year, every year.”
Include chief HPI: M.B. is a 20-year-old Caucasian female who presented to the
complaint, subjective clinic for evaluation since her mother has been complaining that she
information from the always gets moody during winter time. She reported that recently,
patient, names and she has been feeling down, fatigued during daytime, oversleeping
relations of others during her classes, and gaining 10 pounds weight. She reported that
present in the she has been having difficulties in school where she feels that even
interview, and basic though she understands the material, the classes are not interesting
demographic anymore. She reported that she has a difficult time completing her
information of the school projects, and even running late on two assignments. M.B.
patient. HPI, Past stated that has a difficult time concentrating, being unable to
Medical and remember what she has read 5 seconds earlier. Patient stated that
Psychiatric History, she made a lot of friends when she first started college, in August,
Social History. and greatly enjoyed their company but lately she finds them a bit
annoying and dull, and their time spent together decreased
drastically. M.B. reported that she is a summer girl, loves the
sunny ,crips days, enjoys the beach and convertibles, but does not
like this season (winter) because “it’s dark. And gray. And
miserable”. She reported that during the winter the city seems
changed, getting worse and worse, and everything is now grey and
miserable.
Past Psychiatric History:
• General statement: Reported that she has never been under
treatment
• Current Caregivers: Parents
• Hospitalization history: Denies
• Medication history: None
• Psychotherapy/Previous Pychiatric Diagnosis: M.B. has
never been diagnosed with any psychiatric disorders or been
using psychotherapy.
Substance Current use: Reports ocassional alcohol use when going
out with friends but denies cigarette smoking, or other illicit drugs.
Family Pyschiatric history: Patient reported that her mother has an
anxiety disorder, and her paternal grandmother had depression.
Reports no other history and denies any history of suicide in the
family.
Social history: M.B. was born in Alameda County, California, and
raised by both parents. She has one one younger sister who lives
, back home. She moved to NY in August to attend a business
program, lives in a dorm with one roommate, and does not have any
children. She is a full-time student, no violent or traumatic past.
Hobbies: hangs out with friends, traveling and hiking.
Past Medical history: Reports no chronic illnesses. Reports regular
menses, denies taking any type of contraceptives and denies being
sexually active.
Past Surgical history: Reports an appendectomy at age 15.
Medications: none
Allergies: No food/medication allergies. No seasonal allergies.
Spiritual history: Catholic but not practicing.
Immunizations: All vaccinations are up to date
Primary Care Physician: Patient does not see a physician regularly.
ROS:
General : M.B denies fever, generalized weakness, or chills. She
has a recent history of 10 lbs weight gain, and fatigue.
HEENT:
Head, neck, lymph: Denies any pain or discomfort.
Nose, sinuses: Denies pain. No epistaxis or rhinorrhea.
Throat, mouth, pharynx: Denies pain or difficulty with
swallowing.
Neuro: Denies dizziness, numbness or tingling. Reports sleeping
excessively and difficulty concentrating.
Pulm: Denies congestion or dyspnea. Denies cough.
Cardio / vascular: Denies chest pain. Denies cough or dyspnea on
exertion. Denies any palpitations or heart murmurs.
GI / Abdomen: Denies any nausea, vomiting, diarrhea or
constipation. Denies any epigastric or abdominal pain. Reports an
increased appetite
G/U: M.B. denies burning with urination, hematuria, frequency,
dysuria, viaginal discharge or incontinence.
Objective
This is where the Vital Signs
“facts” are located. BP: 112/76 HR: 79 RR: 18 SPO2: 97% T: 98.7
Pain: 0/10
Include relevant labs,
Height: 5’5 Weight: 165 BMI: 27.5 (risk of being overweight)
test results, vitals, and Diagnostic results:
Review of Systems HAM-D: 18 moderate depression
(ROS) – if ROS is CBC: normal
negative, “ROS TSH: normal
noncontributory,” or Blood alcohol content (BAC): normal
“ROS negative with Vitamin B12: normal
Vitamin D: low
the exception of…”
Include MSE, risk Mental Status examination
assessment here, and
psychiatric screening M.B. is a young Caucasian female, who seems to be the stated age,
Criteria Clinical Notes
Subjective CC: “Mom says I get moody this time of year, every year.”
Include chief HPI: M.B. is a 20-year-old Caucasian female who presented to the
complaint, subjective clinic for evaluation since her mother has been complaining that she
information from the always gets moody during winter time. She reported that recently,
patient, names and she has been feeling down, fatigued during daytime, oversleeping
relations of others during her classes, and gaining 10 pounds weight. She reported that
present in the she has been having difficulties in school where she feels that even
interview, and basic though she understands the material, the classes are not interesting
demographic anymore. She reported that she has a difficult time completing her
information of the school projects, and even running late on two assignments. M.B.
patient. HPI, Past stated that has a difficult time concentrating, being unable to
Medical and remember what she has read 5 seconds earlier. Patient stated that
Psychiatric History, she made a lot of friends when she first started college, in August,
Social History. and greatly enjoyed their company but lately she finds them a bit
annoying and dull, and their time spent together decreased
drastically. M.B. reported that she is a summer girl, loves the
sunny ,crips days, enjoys the beach and convertibles, but does not
like this season (winter) because “it’s dark. And gray. And
miserable”. She reported that during the winter the city seems
changed, getting worse and worse, and everything is now grey and
miserable.
Past Psychiatric History:
• General statement: Reported that she has never been under
treatment
• Current Caregivers: Parents
• Hospitalization history: Denies
• Medication history: None
• Psychotherapy/Previous Pychiatric Diagnosis: M.B. has
never been diagnosed with any psychiatric disorders or been
using psychotherapy.
Substance Current use: Reports ocassional alcohol use when going
out with friends but denies cigarette smoking, or other illicit drugs.
Family Pyschiatric history: Patient reported that her mother has an
anxiety disorder, and her paternal grandmother had depression.
Reports no other history and denies any history of suicide in the
family.
Social history: M.B. was born in Alameda County, California, and
raised by both parents. She has one one younger sister who lives
, back home. She moved to NY in August to attend a business
program, lives in a dorm with one roommate, and does not have any
children. She is a full-time student, no violent or traumatic past.
Hobbies: hangs out with friends, traveling and hiking.
Past Medical history: Reports no chronic illnesses. Reports regular
menses, denies taking any type of contraceptives and denies being
sexually active.
Past Surgical history: Reports an appendectomy at age 15.
Medications: none
Allergies: No food/medication allergies. No seasonal allergies.
Spiritual history: Catholic but not practicing.
Immunizations: All vaccinations are up to date
Primary Care Physician: Patient does not see a physician regularly.
ROS:
General : M.B denies fever, generalized weakness, or chills. She
has a recent history of 10 lbs weight gain, and fatigue.
HEENT:
Head, neck, lymph: Denies any pain or discomfort.
Nose, sinuses: Denies pain. No epistaxis or rhinorrhea.
Throat, mouth, pharynx: Denies pain or difficulty with
swallowing.
Neuro: Denies dizziness, numbness or tingling. Reports sleeping
excessively and difficulty concentrating.
Pulm: Denies congestion or dyspnea. Denies cough.
Cardio / vascular: Denies chest pain. Denies cough or dyspnea on
exertion. Denies any palpitations or heart murmurs.
GI / Abdomen: Denies any nausea, vomiting, diarrhea or
constipation. Denies any epigastric or abdominal pain. Reports an
increased appetite
G/U: M.B. denies burning with urination, hematuria, frequency,
dysuria, viaginal discharge or incontinence.
Objective
This is where the Vital Signs
“facts” are located. BP: 112/76 HR: 79 RR: 18 SPO2: 97% T: 98.7
Pain: 0/10
Include relevant labs,
Height: 5’5 Weight: 165 BMI: 27.5 (risk of being overweight)
test results, vitals, and Diagnostic results:
Review of Systems HAM-D: 18 moderate depression
(ROS) – if ROS is CBC: normal
negative, “ROS TSH: normal
noncontributory,” or Blood alcohol content (BAC): normal
“ROS negative with Vitamin B12: normal
Vitamin D: low
the exception of…”
Include MSE, risk Mental Status examination
assessment here, and
psychiatric screening M.B. is a young Caucasian female, who seems to be the stated age,
