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Psychiatric History Assignment Template: Depressive Disorder Case Study, Assignments of Psychiatry

Widener University - Chester Psychiatry

A structured template for completing a psychiatric history assignment, focusing on a case study of a 40-year-old male presenting with a depressive disorder. It includes sections for chief complaint, history of present illness, current medications, past psychiatric and medical history, family and social history, and a review of systems. The template guides students through gathering relevant patient information, documenting symptoms, and understanding the impact of the patient's condition on their daily life. It also covers important aspects such as medication management, family history of mental health issues, and social factors influencing the patient's well-being. This template is designed to help students develop comprehensive psychiatric assessments and improve their clinical skills in mental health care.

Typology: Assignments

2024/2025

Uploaded on 10/17/2025

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Psychiatric History Assignment Template
Initials: AK Age: 40 Gender: Male
Include vital signs if provided . State not provided here if not available.
Allergies (and reaction) NKA
Medication:N/A Click or tap here to enter text.
Food: N/A
Environment: N/A
History of Present Illness (HPI)
Chief Complaint (CC)
Depressive Disorder
CC is a BRIEF statement identifying
why the client is here - in the patient’s
own words - for instance "I have been
feeling depressed," NOT "symptoms of
depression for 3 weeks.” History of
Present Illness (HPI)
(1) develops illness narrative: (cogent
story with clear chronology, not a
list of symptoms), and
(2) includes specific details of
symptoms, and the impact of these
symptoms on daily life.
HPI
Patient is a 40-year-old African American male who presents to the clinic for evaluation of a
depressive disorder. He reports experiencing a significant depressive episode for the past two
weeks. This is his first depressive breakdown, and he describes an array of symptoms that
have markedly affected his daily functioning. He has experienced a significant decrease in
energy levels, which has made it difficult for him to get out of bed and complete daily tasks,
including work responsibilities. Additionally, he reports sleep disturbances characterized by
insomnia, often lying awake for hours at night, and occasionally waking up early in the
morning.
The patient notes difficulties with concentration and decision-making, stating, "I can't focus on
anything and feel like my mind is in a fog."
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. State NA if
no current medications.
Medication
(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time
Used Reason for Use
Labetalol 10mg 1 tablet daily 1 yrs hypertension
Click or tap here to enter text. Click or tap here to
enter text.
Click or tap here to enter
text.
Click or tap here
to enter text.
Click or tap here to enter text.
S: Subjective
Information the client or representative told you
pf3
pf4
pf5

Partial preview of the text

Download Psychiatric History Assignment Template: Depressive Disorder Case Study and more Assignments Psychiatry in PDF only on Docsity!

Psychiatric History Assignment Template

Initials: AK Age: 40 Gender: Male Include vital signs if provided. State not provided here if not available. Allergies (and reaction) NKA Medication:N/A Click or tap here to enter text. Food: N/A Environment: N/A History of Present Illness (HPI) Chief Complaint (CC) Depressive Disorder CC is a BRIEF statement identifying why the client is here - in the patient’s own words - for instance "I have been feeling depressed," NOT "symptoms of depression for 3 weeks.” History of Present Illness (HPI) (1) develops illness narrative: ( cogent story with clear chronology, not a list of symptoms), and (2) includes specific details of symptoms, and the impact of these symptoms on daily life.

HPI

Patient is a 40-year-old African American male who presents to the clinic for evaluation of a depressive disorder. He reports experiencing a significant depressive episode for the past two weeks. This is his first depressive breakdown, and he describes an array of symptoms that have markedly affected his daily functioning. He has experienced a significant decrease in energy levels, which has made it difficult for him to get out of bed and complete daily tasks, including work responsibilities. Additionally, he reports sleep disturbances characterized by insomnia, often lying awake for hours at night, and occasionally waking up early in the morning. The patient notes difficulties with concentration and decision-making, stating, "I can't focus on anything and feel like my mind is in a fog." Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. State NA if no current medications. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Labetalol 10mg 1 tablet daily 1 yrs hypertension Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.

S: Subjective

Information the client or representative told you

Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Psychiatric History - Includes all previous mental health psychotherapy and medication management. Be as descriptive as possible. Include type of provider, name if provided, year(s) of treatment, types of services received, history of trauma, self-harm or harm to others. First psychiatric breakdown, this is the patients first time seeking help for his depressive disorder. Medical History (PMHx) – Includes active medical problems (currently getting managed) and past medical problems (no longer needing any intervention), hospitalizations, and surgeries. Depending on the CC, more info may be needed.

The patient has a medical history significant for hypertension, which has been diagnosed for approximately one year. To

manage his hypertension, he has been prescribed labetalol, an antihypertensive medication, at a dosage of 10 mg once

daily. He has been compliant with this medication regimen since its initiation. The patient reports that his blood pressure

has been well controlled on this medication, with no episodes of severe hypertension or related complications noted. He

monitors his blood pressure regularly at home and follows up with his healthcare provider as recommended.

The patient denies any history of cardiovascular disease, strokes, heart attacks, or other significant medical conditions.

Additionally, there are no reports of surgical interventions in his past medical history. He does not have any allergies to

medications, food, or environmental factors.

Family History (Fam Hx) - History includes, but it is not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include

☐Fever/Chills Click or tap here to enter text. ☐Weight Gain Click or tap here to enter text. ☐Weight Loss Click or tap here to enter text. ☒Trouble Sleeping pt report difficulty falling and staying asleep. ☐Night Sweats Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Photophobia Click or tap here to enter text. ☐Earache Click or tap here to enter text. ☐Tinnitus Click or tap here to enter text. ☐Epistaxis Click or tap here to enter text. ☐Vertigo Click or tap here to enter text. ☐Hearing Changes Click or tap here to enter text. ☐Other: Click or tap here to enter text. Respiratory If patient denies all symptoms for this system, check here: ☒ Neuro If patient denies all symptoms for this system, check here: ☒ Cardiac and Respiratory If patient denies all symptoms for this system, check here: ☐

MSK

If patient denies all symptoms for this system, check here: ☒ ☐Cough Click or tap here to enter text. ☐Hemoptysis Click or tap here to enter text. ☐Dyspnea Click or tap here to enter text. ☐Wheezing Click or tap here to enter text. ☐Pain on Inspiration Click or tap here to enter text. ☐Snoring : Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Syncope or Lightheadedness Click or tap here to enter text. ☐Headache Click or tap here to enter text. ☐Numbness Click or tap here to enter text. ☐Tingling Click or tap here to enter text. ☐Sensation Changes Choose an item. ☐Speech Deficits Click or tap here to enter text. ☐Other: Click or tap here to enter text. ☐Chest pain Click or tap here to enter text. ☐SOB Click or tap here to enter text. Previous cardiac history Click or tap here to enter text. ☒Other: hypertension ☐Pain Click or tap here to enter text. ☐Limited ROM Choose an item. ☐Redness Click or tap here to enter text. ☐ involuntary movements Click or tap here to enter text. ☐Other: Click or tap here to enter text. Hematology/Lymphatics If patient denies all symptoms for this system, check here: ☒

GI

If patient denies all symptoms for this system, check here: ☒

GU

If patient denies all symptoms for this system, check here: ☒ Endocrine If patient denies all symptoms for this system, check here: ☒ ☐Anemia Click or tap here to enter text. ☐Nausea/Vomiting Click or tap here to enter text. ☐Urgency Click or tap here to enter text. ☐ Increased appetite Click or

☐ Other Click or tap here to enter text. ☐Dysphasia Click or tap here to enter text. ☐Diarrhea Click or tap here to enter text. ☐Appetite Change Click or tap here to enter text. ☐Heartburn Click or tap here to enter text. ☐Abdominal Pain Click or tap here to enter text. Click or tap here to enter text. ☒Other: Click or tap here to enter text. ☐Polyuria Click or tap here to enter text. ☐Nocturia Click or tap here to enter text. ☐Incontinence Click or tap here to enter text. ☐Other: Click or tap here to enter text. tap here to enter text. ☐ Increased thirst Click or tap here to enter text. ☐ Thyroid disorder Click or tap here to enter text. ☐ Heat/cold intolerance Click or tap here to enter text. ☐ Excessive sweating Click or tap here to enter text. ☐ Diabetes Click or tap here to enter text. ☐ Other Click or tap here to enter text.