What history and physical examination are indicated for a 35-year-old female with a three-month history of persistent low mood, anhedonia, fatigue, concentration difficulties, decreased appetite with 5‑lb weight loss, insomnia, feelings of worthlessness, passive death wishes, no active suicidal ideation, no substance use, and no significant past medical history?

History and Physical Examination for Depression

For this 35-year-old female presenting with classic depressive symptoms, conduct a focused psychiatric history to confirm major depressive disorder diagnosis and a targeted physical examination to exclude medical mimics, particularly thyroid disease and substance use.

Psychiatric History

Core Diagnostic Criteria Assessment

The patient already meets DSM criteria for major depressive disorder, but systematically document all nine symptom domains 1:

• Depressed mood: Duration (3 months documented), frequency (nearly every day), severity
• Anhedonia: Loss of interest/pleasure in previously enjoyed activities
• Appetite/weight changes: 5-lb weight loss documented—clarify if intentional
• Sleep disturbance: Insomnia pattern (initial, middle, or terminal)
• Psychomotor changes: Observable agitation or retardation (not just subjective)
• Fatigue/energy loss: Impact on daily functioning
• Worthlessness/guilt: Distinguish from appropriate guilt; assess for delusional quality
• Concentration difficulties: Impact on work performance, decision-making
• Death wishes/suicidal ideation: Critical safety assessment

Suicide Risk Assessment

This patient has passive death wishes—immediate detailed evaluation is mandatory 2, 3, 2:

• Current suicidal intent: "Do you have a plan to kill yourself? How would you do it?"
• Access to means: Firearms in home, medications available, other lethal means
• Prior attempts: Method used, lethality, circumstances
• Protective factors: Reasons for living, family support, willingness to seek help
• Risk factors: Living alone, social isolation, hopelessness (strong predictor of poor treatment response) 2

Key distinction: Passive death wishes ("better off dead") versus active suicidal ideation with plan and intent determines immediate disposition.

Rule Out Medical and Substance Causes

The DSM explicitly requires excluding physiologic causes 1:

• Medication history: Current and recent medications (corticosteroids, beta-blockers, interferon, isotretinoin, hormonal contraceptives)
• Substance use: Alcohol quantity/frequency, illicit drugs, prescription misuse—patient denies but verify
• Medical conditions: Hypothyroidism, anemia, diabetes, chronic pain, neurological disorders
• Recent life events: Bereavement (symptoms >2 months or severe functional impairment still warrant MDD diagnosis) 1

Functional Impairment

Document specific impacts on:

• Occupational: Work attendance, performance, relationships with colleagues
• Social: Withdrawal from friends, family conflicts
• Self-care: Hygiene, nutrition, activities of daily living

Psychiatric Comorbidities

Screen for conditions that alter treatment approach 2:

• Anxiety disorders: Panic attacks, generalized anxiety, PTSD
• Bipolar disorder: Critical—any history of manic/hypomanic episodes (decreased need for sleep, racing thoughts, impulsivity, grandiosity, pressured speech) 2, 3
• Psychotic symptoms: Hallucinations, delusions (indicates severe depression requiring different treatment)
• Personality patterns: Chronic interpersonal instability, impulsivity

Family and Social History

• Family psychiatric history: Depression, bipolar disorder, suicide, substance abuse 2
• Childhood trauma: Physical/sexual abuse, neglect
• Current support system: Living situation, relationships, financial stressors
• Cultural/religious factors: Impact on symptom expression and treatment acceptance

Physical Examination

Vital Signs and General Appearance

• Weight: Document current weight for baseline (5-lb loss already noted)
• Vital signs: Blood pressure, heart rate (rule out medical instability)
• General appearance: Grooming, hygiene, psychomotor retardation or agitation (observable, not just reported) 1

Mental Status Examination

• Appearance: Disheveled, poor eye contact, tearful
• Behavior: Psychomotor slowing, agitation, restlessness
• Speech: Rate, volume, latency of response
• Mood: Patient's subjective report ("depressed," "empty," "hopeless")
• Affect: Observed emotional expression (constricted, flat, tearful, congruent with mood)
• Thought process: Linear, goal-directed versus tangential, circumstantial
• Thought content: Suicidal ideation, hopelessness, worthlessness, guilt
• Perceptual disturbances: Hallucinations (auditory, visual)
• Cognition: Attention, concentration, memory (often impaired in depression)
• Insight and judgment: Understanding of illness, willingness to accept treatment

Targeted Physical Examination to Exclude Medical Causes

• Thyroid: Palpate for enlargement, nodules (hypothyroidism mimics depression)
• Cardiovascular: Heart sounds, peripheral edema (cardiac disease can present with fatigue)
• Neurological: Focal deficits, tremor, gait abnormalities (rule out neurological disorders)
• Skin: Pallor (anemia), jaundice, bruising (liver disease, nutritional deficiency)

Laboratory and Screening Considerations

While the 2016 ACP guideline 4 and screening recommendations 5, 6 focus on treatment rather than specific laboratory workup, standard practice dictates:

Minimum initial workup (to exclude medical mimics):

• Thyroid-stimulating hormone (TSH): Hypothyroidism is a common reversible cause
• Complete blood count (CBC): Anemia causes fatigue
• Comprehensive metabolic panel: Electrolyte abnormalities, renal/hepatic function
• Pregnancy test: If applicable (affects medication choices)

Additional testing based on clinical suspicion:

• Vitamin B12, folate if dietary concerns
• Toxicology screen if substance use suspected despite denial
• HIV, RPR if risk factors present

Clinical Decision Points

Immediate Hospitalization Indicated If:

• Active suicidal ideation with plan and intent
• Psychotic symptoms
• Severe functional impairment with inability to care for self
• Lack of adequate support/supervision 3, 2

Outpatient Management Appropriate If:

• Passive death wishes without active plan
• Adequate support system
• Patient agrees to safety plan
• No psychotic symptoms
• Able to function in daily activities 3, 2

Treatment Initiation

The 2016 ACP guideline provides clear direction: Select either cognitive behavioral therapy or second-generation antidepressants after discussing effects, side effects, cost, and accessibility with the patient 4. Both have equivalent efficacy for moderate depression.

Common Pitfalls to Avoid

1. Dismissing passive suicidal ideation: Any death wishes require thorough assessment 7
2. Missing bipolar disorder: Antidepressants alone can precipitate mania—always screen for hypomanic/manic history 2
3. Inadequate substance use history: Patients may minimize use; collateral information is valuable
4. Overlooking hypothyroidism: Single most common medical mimic
5. Failing to assess functional impairment: Required for DSM diagnosis 1
6. Relying solely on screening tools: PHQ-9 or other instruments complement but never replace clinical interview 5, 6
7. Not obtaining collateral information: Family/friends provide crucial context, especially regarding suicidality 3, 2