Identifying Information:
- Detail patient’s name or initials, age, gender, and date of consultation
Reason for Consultation:
- Provide detailed statement of the presenting problem or purpose of the appointment including type and nature of symptoms, length of time with symptoms, external stressors, interpersonal or relationship factors, impact on functioning, and other relevant information
Personal and Developmental History:
- Describe patient’s personal and developmental history including early development, family history and structure, education and employment history, occupation, current living arrangements, and social support
- Describe any history of trauma, including family or intergenerational trauma, or significant adversity
- Describe family history of any illness or medical condition, including psychiatric illness and neurodevelopmental conditions, family suicides, or family addiction behaviours
Current Key Lifestyle Indicators:
- Describe the patient’s current sleep pattern and sleep hygiene
- Describe the patient’s current diet, including binge behaviours, caffeine intake, quality of nutrition
- Describe the patient’s current level of physical exercise or general activity levels
- Describe the patient’s level of social functioning, including quality and quantity of social and family relationships, efforts at connecting socially, and extent of any social isolation
Medical Status and Medical History:
- List previous non-psychiatric diagnoses and medical conditions, including information about when diagnosis was made, by whom, and patient’s responses to treatment
Psychiatric Illness History:
- List previous psychiatric diagnoses and conditions, including when diagnosed, by whom, and responses to treatment
- Describe any previous psychological interventions, including therapists, online programs, or group programs
- Describe any past hospitalisations for mental health reasons, including locations, key medical personnel, and dates
Medication History:
- List all current medications, including psychotropic and non-psychotropic, with doses and frequencies
- Describe medication history including response to past medications, side effects, adverse reactions, and adherence to previous regimens
Drug and Alcohol Use History:
- Describe patient’s current level of alcohol consumption, cigarette or vape use, and any other recreational or illicit substance use
- Describe any past or current misuse of prescription medications
Other Addiction History:
- Describe any other potentially problematic addictive behaviours mentioned by the patient, even if not viewed as problematic by the patient
Legal and Forensic History:
- Describe any previous history involving illegal activity, interactions with justice system, imprisonment, family law system interactions, or domestic violence behaviour
Mental Status Examination (MSE):
If not stated in the transcript, print the subtitle and leave blank.
- Appearance: Describe the patient’s general physical appearance, hygiene, grooming, and attire
- Behaviour: Describe the patient’s interaction with surroundings, activity level, psychomotor activity, eye contact, and rapport
- Speech: Describe the rate, volume, tone, coherence, and articulation of the patient’s speech
- Mood and Affect: Describe the patient’s reported mood and emotional state using their own words if possible, range and appropriateness of emotional response, and any discrepancies
- Thought Process: Describe the patient’s coherence, organisation, and flow of thoughts
- Thought Content: Describe the content of the patient’s thoughts, noting presence of delusions, distortions, obsessions, or intrusive thoughts
- Perception: Describe hallucinations or other perceptual disturbances
- Cognition: Describe the patient’s orientation to time/place/person, attention, memory, concentration, and comprehension
- Insight and Judgment: Describe the patient’s understanding of their mental health condition and decision-making capacity
Strengths, Coping Skills, Recreational Interests, and Hobbies:
- List the patient’s strengths, positive coping skills, recreational interests, hobbies, and other protective factors that are helpful for managing mental health
Psychometric Assessment:
- Summarise any psychometric testing results, including scores and interpretation
- Detail any plans mentioned by the psychiatrist to conduct future psychometric testing
Formulation:
- Provide detailed bio-psycho-social psychiatric formulation, including predisposing, precipitating, perpetuating and protective factors
- Include psychodynamic formulation if applicable
- Include evidence from the transcript to enhance formulation details
Diagnosis:
- Describe the psychiatrist’s diagnostic impressions and observations, based on DSM-5-TR and ICD-11 criteria
- Include diagnostic codes and specify if diagnoses are new or confirmation of previous diagnoses
- Detail any comorbidities or differential diagnosis considerations
Risk:
- Make risk assessment statement regarding suicidal or homicidal ideation, self-harm or harm to others, and risk of relapse
- Include information about past suicide attempts or self-harming behaviour
- Include psychosocial stressors contributing to risk level
- Describe protective factors that mitigate risk
Treatment Plan Discussed With Patient:
- Specify evidence-based recommendations for medication changes, continuing or discontinuing existing medications, and psychiatrist’s rationale
- Specify suggested non-pharmacological interventions such as psychotherapy or lifestyle modifications with rationale
- Specify referrals to other specialists or services with rationale
- Detail plan for follow-up and monitoring including next appointment details
- Detail any Safety Plan made in event of risk to safety including crisis steps
- Summarise education provided about diagnosis and treatment options, documenting patient’s understanding and agreement
Summary:
- Provide brief paragraph summary of the appointment in no more than four sentences
Other Practitioners:
- Detail names, locations, organisations and contact details of other practitioners involved in the patient’s care, including doctors, case managers, lawyers, or other contacts
Identifying Information:
- Patient: Mary B., 32-year-old female
- Consultation date: 22/05/2025
Reason for Consultation:
Mary presents with a three-month history of persistent low mood, anxiety, and sleep disturbance following the breakdown of her marriage and subsequent divorce proceedings. She reports significant anhedonia, social withdrawal, and difficulty concentrating at work as a primary school teacher. The symptoms began gradually after her husband left the family home in February 2025, intensifying during recent custody negotiations regarding their two young children. Mary describes feeling overwhelmed by single parenting responsibilities while managing her teaching workload, leading to decreased performance in both areas and concerns from her school principal about her wellbeing. She also reports intrusive thoughts about her worthlessness as a wife and mother, with episodes of panic when receiving legal correspondence about the divorce.
Personal and Developmental History:
- Mary grew up in a stable two-parent household as the eldest of three children, achieving well academically and completing a Bachelor of Education
- She married her husband at age 25 and has two children aged 6 and 8 years
- Currently living in the former family home with the children, receiving limited financial support from her ex-husband
- Significant childhood trauma includes witnessing domestic violence between her parents from age 8-12, with her father’s alcoholism and verbal aggression toward her mother before her parents divorced when she was 13
- Mary reports taking on a caretaking role for her younger siblings during this period and feeling responsible for her mother’s emotional wellbeing
- Family history notable for maternal depression requiring hospitalisation when Mary was 15, and paternal history of alcohol use disorder
Current Key Lifestyle Indicators:
- Sleep pattern severely disrupted with difficulty falling asleep until 2-3 AM and early morning waking at 4 AM, resulting in 3-4 hours sleep nightly
- Physical exercise has ceased completely since marriage breakdown, previously walked regularly for stress management
- Social functioning significantly impaired with complete withdrawal from friendships and family relationships, avoiding social situations and declining invitations
Medical Status and Medical History:
- No significant medical conditions reported aside from recurrent headaches since onset of current episode
- Currently takes no regular medications though reports frequent use of over-the-counter pain medication for headaches
Psychiatric Illness History:
- No previous psychiatric diagnoses or formal treatment
- Brief episode of anxiety during university exams and again during her mother’s hospitalisation but did not seek professional help
- Reports period of low mood lasting several months following birth of second child but attributed this to normal adjustment
Medication History:
- No current or previous psychotropic medications
- Occasional use of paracetamol and ibuprofen for headaches
Drug and Alcohol Use History:
- Alcohol consumption increased to 2-3 glasses of wine nightly since separation, occasionally up to a full bottle on weekends
- No tobacco use or illicit substance use reported, though acknowledges concern about current drinking pattern
Other Addiction History:
- Reports compulsive checking of ex-husband’s social media accounts multiple times daily
- No other problematic addictive behaviours identified
Legal and Forensic History:
- Currently involved in family court proceedings regarding custody arrangements with next hearing scheduled for June 2025
- No other legal issues reported, though expresses anxiety about potential financial implications of divorce settlement
Mental Status Examination (MSE):
- Appearance: Well-groomed woman appearing tired with dark circles under eyes and noticeable weight loss
- Behaviour:
- Speech: Normal rate and volume with occasional tremor in voice when discussing children, some pressure of speech when discussing legal concerns
- Mood and Affect: Self-described mood as “devastated and hopeless,” affect congruent and depressed with episodes of anxiety when discussing future
- Thought Process: Generally coherent and goal-directed with some rumination about marriage failure and self-blame
- Thought Content: Preoccupied with divorce proceedings and children’s wellbeing, themes of personal failure and inadequacy, no delusions but catastrophic thinking about future
- Perception: No hallucinations or perceptual disturbances reported
- Cognition: Fully oriented with some impairment in concentration and working memory, particularly when anxious
- Insight and Judgment: Good insight into current difficulties and recognises need for help, judgment generally intact though some impaired decision-making regarding alcohol use
Strengths, Coping Skills, Recreational Interests, and Hobbies:
- Strong dedication to her children’s wellbeing and maintaining their routines despite personal distress
- Previously enjoyed reading historical fiction and gardening before current episode
- Good problem-solving skills demonstrated in professional teaching role and previous ability to manage work-life balance
- Strong work ethic and commitment to education, respected by colleagues and parents
Psychometric Assessment:
- DASS-21 administered with Depression score of 28 (severe range), Anxiety score of 16 (moderate range), and Stress score of 24 (moderate range)
- Results indicate clinically significant depression with moderate levels of anxiety and stress
Formulation:
Mary’s presentation represents a major depressive episode with anxiety features precipitated by marital breakdown and divorce proceedings. Predisposing factors include childhood exposure to domestic violence and parental mental illness, creating vulnerability to relationship trauma and tendency toward self-blame. Her history of taking on caretaking roles from an early age may contribute to current feelings of failure when unable to maintain her marriage. Precipitating factors include her husband’s departure and ongoing legal stress. Perpetuating factors include social isolation, disrupted sleep, increased alcohol use, and rumination about personal inadequacy. Protective factors include her commitment to her children, stable employment, and good insight into her difficulties. The pattern of symptoms suggests both reactive depression to life stressors and possible underlying vulnerability related to early trauma exposure.
Diagnosis:
- Major Depressive Disorder, moderate severity, single episode (F32.1)
- Alcohol Use Disorder, mild severity (F10.10) – emerging pattern requiring monitoring
Risk:
Mary denies current suicidal ideation but reports passive thoughts that “everyone would be better off without me” and occasional fleeting thoughts of driving into oncoming traffic, though she states she would never act on these due to her children. No history of suicide attempts or deliberate self-harm behaviours. Current high-risk factors include ongoing custody stress, financial pressures, social isolation, and increased alcohol use. Protective factors include strong maternal bond with her children, maintaining employment, and seeking help voluntarily. Risk is assessed as moderate with need for close monitoring.
Treatment Plan Discussed With Patient:
- Commence sertraline 50mg daily with plan to review in two weeks and titrate to 100mg as needed, discussed common side effects and importance of adherence
- Referral to psychologist specialising in trauma and depression for cognitive behavioural therapy focusing on processing childhood trauma, current adjustment difficulties, and developing healthy coping strategies
- Recommendation for GP review to assess physical health, address headaches, and monitor alcohol consumption with brief intervention
- Psychoeducation provided about depression, anxiety, and the impact of alcohol on mood and sleep
- Follow-up appointment scheduled in two weeks to monitor medication response, side effects, and symptom improvement
- Safety planning discussed with instruction to contact crisis services or present to emergency department if thoughts of self-harm emerge, written safety plan provided
- Discussion about reducing alcohol consumption and referral to alcohol counselling service if needed
Summary:
Mary presents with major depressive disorder triggered by marital breakdown, with underlying vulnerability related to childhood trauma exposure and emerging alcohol use concerns. She demonstrates good insight and motivation for treatment despite significant current distress. Comprehensive treatment plan includes antidepressant medication, psychological therapy addressing both current stressors and historical trauma, and close monitoring of risk factors including alcohol use.
Other Practitioners:
- Dr. James Jones, GP, NovoPsych Medical Centre, (03) 8888 5555
- Rebecca Ross, Family Lawyer, NovoPsych Legal Services, (03) 9999 3333
