Using the format below, write me a comprehensive and detailed psychiatry interview for a 31-year-old female patient who came into the clinic for depression. Patient name is PATIENT 1

1. Chief Complaint (CC): The chief complaint is the reason given by the patient for seeking medical care. The CC should be a 2-3 word description of why they are at the office today.

You can assess this by asking: "Can you tell me why you are here today?" or "Tell me how you are feeling right now" or "Can you share with me what brings you to the office today?"

1. History of Present Illness (HPI): Describes the course of the patient's illness, including when it began, the character of symptoms, the location where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness. While obtaining the HPI, it is important to incorporate "OLD CARTS".

O = Onset (Was it an acute or gradual onset? When did your symptoms begin? Did they develop suddenly or over a period of time? Does anyone you know or have been in contact with have similar symptoms? Are you experiencing symptoms now?)

L = location (Where is the pain or symptom located? Is it in a specific area? Does the symptom radiate to another location?)

D = Duration (When you experience this, how long does it last? Since the symptoms began, have they become worse? Are they intermittent?)

C = Characteristics (Describe the symptoms? Dull, sharp, intermittent? Describe how the symptoms feel or look? Describe the sensation: stabbing, dull, aching, throbbing?)

A = Aggravating factors ( What makes it worse? What are the symptoms aggravated by? Walking, eating, position? )

R = Relieving factors (What makes it better? What relieves the symptoms?)

T = Treatments (What have you tried to resolve the problem? What was the response to that treatment? Have you continued with that treatment, or if you have not, why? If you have tried anything to manage your symptoms, what medication and dose have you taken?)

S = Severity(How severe is this? On a scale of 1-10, with ten being the most severe, can you rate your pain?)

1. Psychiatric Review of Symptoms:This should include current symptoms typically presenting within the past two weeks.

You can assess this by asking about:

Current anxiety symptoms (easily startled, jittery, hypervigilance, excessive worry), racing thoughts, ruminations, panic attacks

Depression symptoms (down, depressed, hopeless), thoughts/intent/plan to harm self or others.

Changes in sleep and appetite

Changes in mood, grandiosity or impulsivity

Changes in concentration and memory

Aggressiveness, irritability, aloofness or withdrawal.

Auditory/visual/tactile/olfactory hallucinations, fears, phobias, paranoia, or fixations

Changes in the ability to follow through with tasks, or attend to work, home, and school obligations

Changes in self-care routines, hygiene

1. Psychiatric History:This should include past data and any current data not addressed previously.

You can assess this by asking about

Past and current psychiatric diagnoses.

Prior psychotic or aggressive ideas, including thoughts of physical or sexual aggression or homicide.

Prior aggressive behaviors (e.g., homicide, domestic or workplace violence, other physically or sexually aggressive threats or acts).

Prior suicidal ideas, suicide plans, and suicide attempts, including aborted or interrupted ones, as well as details of each attempt (e.g., context, method, damage, potential lethality, intent).

Prior intentional self-injury in which there was no suicide intent.

History of psychiatric hospitalization and/or emergency department visits for psychiatric issues.

Past psychiatric treatments (type, duration, and, where applicable, doses).

Response to past psychiatric treatments.

Adherence to past and current pharmacological and nonpharmacological psychiatric treatments.

1. Past Medical/Surgical History:Ask the patient to share their past medical history. If the patient is not forthcoming with information, you may need to ask specifically about health conditions.

You can assess this by asking: "Can you please tell me about your medical history?" or "What medical problems have you had?"

Additional questions may be: "Have you ever been pregnant?" or "How many children do you have?"

Additionally, ask about:

Environmental and food allergies (Medication allergies are addressed later)

Whether or not the patient has an ongoing relationship with a primary healthcare professional.

Past or current medical illnesses and related hospitalizations.

Relevant past or current treatments, including surgeries, other procedures, or complementary and alternative medical treatments.

Immunization status.

Past or current neurological or neurocognitive disorders or symptoms.

Physical trauma, including head injuries.

Sexual and reproductive history.

Cardiopulmonary status.

Past or current endocrinological disease.

Past or current infectious diseases, including sexually transmitted diseases, HIV, tuberculosis, hepatitis C, and locally endemic infectious diseases, such as Lyme disease.

Past or current symptoms or conditions associated with significant pain and discomfort.

1. Family HistoryYou can assess this by asking: "Can you tell me about your family history?" or "Does your mother, father, or siblings have any medical or psychiatric history?" or"Are your parents alive and well?"

Specifically ask about:

History of suicidal behaviors

History of violent behaviors

Psychiatric illness

Substance use disorders

1. Substance Use History

You can assess this by asking about:

Use of tobacco, alcohol, and other substances (e.g., marijuana, cocaine, heroin, hallucinogens) and any misuse of prescribed or over-the-counter medications or supplements.

Current or recent substance use disorders or change in use of alcohol or other substances.

Any current or prior treatment for substance use disorders

1. Personal and Social HistoryAsk the patient about education level, occupational history, current living situation/partner/marital status, and substance use/abuse, ETOH, tobacco, and marijuana (if not done so already), safety status, and support status.

You can assess this by asking, "How many years of education do you have?" or " What do you do for a living?", or "How do you spend your time?" or "Do you currently live alone or with someone else?" and "In an apartment, house or somewhere else?" adding, "Do you feel safe where you live?" and "Who in your life can you count on for support?"

Specifically, you can assess this through inquiry of:

Presence of psychosocial stressors (e.g., financial, housing, legal, school/occupational, or interpersonal/relationship problems; lack of social support; painful, disfiguring, or terminal medical illness).

Review of the patient's trauma history.

Exposure to violence or aggressive behavior, including combat exposure or childhood abuse.

Legal or disciplinary consequences of past aggressive behaviors.

Literacy or learning difficulties

Cultural factors related to the patient's social environment.

Personal/cultural beliefs and cultural explanations of psychiatric illness.

Patient's need for an interpreter.

1. Medications:Ask the patient about the medications, frequency, and dosages of current medications.

You can assess this by asking: "What prescribed and over-the-counter medications do you take?"

1. Medication allergies:Ask the patient if they have any medication allergies and have them describe their allergic response to the medications. You could also request for the patient to share any additional allergies that they may have.

You can assess this by asking: "Are you allergic to any medications?" or "Do you have any allergies?" or "Are you allergic to anything?"

1. Medical Review of SystemsYou can assess this through a brief inquiry of systems at the first visit, and an updated inquiry at subsequent visits e.g., Have there been any changes to your general health or medical conditions?

• General:Weight change, fatigue, fever, chills, night sweats, and change energy level
• Skin: Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles
• Eyes: Corrective lenses, blurring, and visual changes of any kind
• Ears: Ear pain, hearing loss, ringing in ears, and discharge
• Nose/Mouth/Throat: Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain
• Breast:SBE, lumps, bumps, or changes
• Heme/Lymph/Endo:HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance
• Cardiovascular: Chest pain, palpitations, PND, orthopnea, and edema
• Respiratory: Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB
• Gastrointestinal: Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools
• Genitourinary/Gynecological:Urgency, frequency burning, change in color of urine. Contraception, sexual activity, STDs. Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx. Male: prostate, PSA, urinary complaints
• Musculoskeletal: Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis
• Neurological: Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells

After you have completed all components above, you will then let the patient know that you would like to proceed to ask a few more questions and/or obtain more data through standardized tests in order to help inform the plan of care. You would then proceed to obtain the patient's assent to gather any additional information needed to complete a full Mental Status Exam.If necessary, you would tell the patient, "I'd like to gather a little more information to help get a better picture of how to help you best, would that be okay?"At that point, you would administer any standardized tests or proceed with additional questioning, safety assessment, etc.