Full Answer Section

• Onset: Symptoms began gradually approximately four months ago, with a noticeable worsening over the past two months. There is no single, clear precipitating event identified by the patient, but he acknowledges increased work-related stress in recent months.
• Location: The patient reports that these feelings affect all aspects of his life, including his work performance, social interactions, and personal well-being.
• Duration: His symptoms have been continuous for the past four months, occurring nearly every day for most of the day.
• Characteristics: He describes his sadness as a heavy, pervasive emptiness. He notes that activities he once enjoyed, such as playing golf and reading, now hold no appeal. The fatigue is constant, even after attempting to get adequate sleep.

Slide 4: History of Present Illness (HPI) - Part 2

• Aggravating/Alleviating Factors: Symptoms are typically worse in the mornings. He reports no significant alleviating factors, despite trying over-the-counter sleep aids (which were ineffective for his insomnia) and increasing caffeine intake (which only made him feel more agitated without improving mood or energy).
• Associated Symptoms: Mr. A.J. reports increased irritability, occasional episodes of tearfulness, and significant social withdrawal. He also notes a decreased libido. He denies any suicidal ideation, homicidal ideation, hallucinations, delusions, or manic/hypomanic symptoms.
• Severity: The patient rates his mood as 2/10, where 10 is the best he's ever felt. He reports significant functional impairment, including missing several days of work, declining performance, and strained relationships due to his withdrawal.
• Treatments Tried: As mentioned, he has attempted self-management with OTC sleep aids and caffeine, without success. He has not sought professional mental health treatment prior to this visit.
• Impact on Life: His occupational functioning has significantly deteriorated, leading to missed deadlines and errors. He has become socially isolated, declining invitations from friends and family. He also reports neglecting personal hygiene and self-care.

Slide 5: Review of Systems (ROS)

• General: Reports significant fatigue, unintentional weight loss (approximately 10 lbs over 4 months due to decreased appetite), and generalized weakness. Denies fever, chills, night sweats.
• HEENT: Denies headaches, vision changes, hearing changes, sore throat, or nasal congestion.
• Cardiovascular: Denies chest pain, palpitations, shortness of breath, or edema.
• Respiratory: Denies cough, wheezing, or difficulty breathing.
• Gastrointestinal: Reports decreased appetite, occasional mild nausea. Denies abdominal pain, diarrhea, constipation, or heartburn.
• Genitourinary: Denies dysuria, frequency, urgency, or hematuria. Reports decreased libido.
• Musculoskeletal: Denies joint pain, muscle aches, or stiffness.
• Neurological: Denies dizziness, syncope, numbness, tingling, or seizures. Reports difficulty concentrating.
• Endocrine: Denies heat/cold intolerance, excessive thirst or urination.
• Hematologic/Lymphatic: Denies easy bruising/bleeding, swollen lymph nodes.
• Allergic/Immunologic: Denies new allergies or frequent infections.
• Psychiatric: Endorses depressed mood, anhedonia, fatigue, feelings of worthlessness, insomnia (difficulty falling and staying asleep), decreased appetite, and difficulty concentrating. Denies suicidal/homicidal ideation, paranoia, hallucinations, or manic symptoms.

Slide 6: Objective Data - Medical Information

• Current Medications:
  • Multivitamin (daily)
  • Ibuprofen (as needed for occasional headaches)
• Allergies:
  • No Known Drug Allergies (NKDA)
  • No known food or environmental allergies
• Past Medical History (PMH):
  • Childhood asthma (resolved, no current symptoms or medication)
  • Seasonal allergies (managed with OTC antihistamines as needed)
  • No history of major surgeries, hospitalizations, or other chronic medical conditions.

Sample Answer

Clinical Case Presentation: Mr. A.J.

Slide 1: Title Slide

• Presenter: [Your Name/Role]
• Date: May 22, 2025

Slide 2: Chief Complaint & Demographics

• Patient Initials: A.J.
• Age: 45 years old
• Gender: Male
• Ethnicity: Caucasian
• Marital Status: Divorced (2 years ago)
• Occupation: Accountant

Slide 3: History of Present Illness (HPI) - Part 1

• Presenting Problem: Patient reports a pervasive low mood, loss of interest or pleasure in nearly all activities (anhedonia), significant fatigue, difficulty concentrating, and feelings of worthlessness. He also reports changes in sleep and appetite.