Subjective
Date of visit
Reason for visit (initial evaluation for suspected post-MI depression, follow-up for diagnosed post-MI depression)
History of present illness:
Onset and duration of depressive symptoms following MI (e.g., feeling down, loss of interest or pleasure, changes in sleep or appetite)
Severity of symptoms (using a standardized depression rating scale like PHQ-9)
Presence of anxiety symptoms (e.g., worry, racing thoughts, panic attacks)
Functional impact of depression (e.g., difficulty with daily activities, social withdrawal)
Medical history of depression or other mental health conditions
Past medical history:
Details of the myocardial infarction (date, severity, treatment)
Presence of any pre-existing cardiovascular risk factors (e.g., hypertension, diabetes, hyperlipidemia)
Other relevant medical conditions
Social History
Living situation and social support system
Occupational history and current employment status
Financial stressors
Family History
Family history of depression or other mental health conditions
Medications
Current medications (including cardiac medications)
Any history of medication trials for depression
Allergies
Allergies to medications (important for considering treatment options)
Objective
Mental status examination:
Mood (depressed, anxious, irritable)
Affect (congruent with mood, blunted)
Thought processes (presence of suicidal ideation)
Psychomotor activity (psychomotor retardation or agitation)
Cognitive function (orientation, memory, concentration)
Physical exam (brief general physical exam to rule out medical causes of depression)
Assessment
Suspected post-MI depression based on clinical presentation and symptom criteria
Severity of depression (mild, moderate, severe)
Presence of suicidal ideation or risk factors
Consideration of differential diagnoses (e.g., adjustment disorder, medication side effects)
Plan
Initiation or continuation of treatment for post-MI depression:
Psychotherapy (individual or group cognitive behavioral therapy – CBT) – first-line treatment
Antidepressant medication (consider potential interactions with cardiac medications) – may be used in combination with psychotherapy
Cardiac rehabilitation program (encouraged for overall well-being)
Address any suicidal ideation or safety concerns
Referral to a mental health professional for ongoing treatment (if not already established)
Education
Explain the link between myocardial infarction and depression
Discuss the importance of addressing depression for overall health and recovery
Provide psychoeducation about depression and treatment options (psychotherapy, medication)
Importance of medication adherence and potential side effects (if applicable)
Follow-up
Schedule for follow-up appointments:
Monitor response to treatment (symptom improvement, depression rating scales)
Adjust treatment plan as needed
Monitor for medication side effects
Address any ongoing challenges or concerns
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of post-myocardial infarction depression.