Informed Consent
The patient was presented with informed consent about the psychiatric interview process and
treatment. She verbally agreed and signed the informed consent to be treated.
Identifying Data
Name: Sarah
...
Informed Consent
The patient was presented with informed consent about the psychiatric interview process and
treatment. She verbally agreed and signed the informed consent to be treated.
Identifying Data
Name: Sarah O'Neil Age: 25 years old Gender: Female
Sarah, a 25-year-old female, Depression
Subjective:
Chief Complaint: Depression. "I've been so sad almost every day for the past month."
HPI
Sarah is aged 25 years and married. Her primary physician referred her to the emergency
department care for a depression diagnosis after a physical examination revealed no organic
explanations. Sarah came to PCP for an evaluation after her manager encouraged her to do so
due to sobbing bouts at work and impaired work performance. Sarah has been sad every day for
the past month and "every minute of the day" for the previous two weeks, according to her. She
supports suicidal thoughts but says she would not act on them because of her family and faith.
She's having paranoid thoughts and feels her coworkers are conspiring to get her fired. Sarah
also claims that about six weeks ago, she went days without sleeping, attempted to write a novel,
and acted in a way that was out of character for her. She went to a pub by herself, considered
having an extramarital affair, almost left with a male stranger, and passed out. Sarah also claims
to have gained weight recently and is dissatisfied with her appearance. Her sadness affects her
employment and relationships, and her marriage is suffering. Sarah recalls a previous depressive
period in high school, during which she engaged in self-harming behavior. Family history is
crucial because of the mother's illness and suicide seven years ago, the father's alcoholism, and
the sister's sadness
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