Psychiatrist's note (custom)

Chief Complaints * Anxiety * Depressed mood Demographics Patient lives alone, is unemployed, and is currently single. No children. History of Presenting Complaints Patient presents with symptoms of anxiety and depressed mood. The patient reports feeling overwhelmed by daily tasks and experiencing persistent worry. They also report a loss of interest in activities they previously enjoyed, along with feelings of sadness and hopelessness. The patient reports difficulty sleeping and changes in appetite. The patient reports that the symptoms have been present for the past three months. Patient reports associated symptoms of fatigue, difficulty concentrating, and irritability. Past Psychiatric History Patient was previously diagnosed with Major Depressive Disorder and Generalised Anxiety Disorder. The patient has been treated with psychotherapy and medication in the past. The patient was hospitalised for a suicide attempt two years ago. Current medications: * Sertraline 100mg daily * Lorazepam 1mg as needed for anxiety Medical History * Hypertension Family History Patient's mother has a history of depression. Patient's father has a history of alcohol use disorder. Substance History Patient reports occasional alcohol use, approximately one to two drinks per week. Patient denies any use of recreational drugs. Patient is a non-smoker. Social and Developmental History Patient has a strong support network of friends. Patient reports a normal birth and developmental milestones. They attended primary and secondary school without any significant issues. They completed a Bachelor's degree. They have been employed in various administrative roles. They have no children. Mental Status Examination - Appearance: Patient is dressed in casual clothing and appears well-groomed. - Behaviour: Patient is restless and fidgety. - Speech: Speech is normal in rate and volume, but the patient has a tendency to speak quickly. - Mood: Patient reports feeling sad and anxious. - Affect: Affect is constricted. - Thoughts: Patient reports negative thoughts about themselves and the future. No evidence of delusions or hallucinations. - Perceptions: No reported hallucinations. - Cognition: Oriented to person, place, and time. Memory is intact. Concentration is slightly impaired. - Insight: Patient acknowledges their mental health condition and its impact on their life. - Judgment: Judgment is intact. Risk Assessment Patient reports suicidal ideation, but denies any current plans or intent. Patient denies homicidal ideation. Patient has a history of self-harm. Diagnosis Major Depressive Disorder, Generalised Anxiety Disorder. DSM-5 criteria met. GAD-7 score: 14. PHQ-9 score: 18. Treatment Plan Investigations: Routine blood work to assess for any underlying medical conditions. Medications: * Continue Sertraline 100mg daily * Continue Lorazepam 1mg as needed for anxiety Psychotherapy: Continue weekly Cognitive Behavioral Therapy (CBT) sessions. Family meetings, collateral information, psychosocial interventions: Encourage patient to attend support groups. Follow-up appointments and referrals: Schedule follow-up appointment in four weeks. Refer to a psychiatrist for medication management. Safety Plan Patient will contact their therapist or psychiatrist if they experience suicidal thoughts. Patient will call the crisis hotline if they feel overwhelmed. Patient will avoid alcohol and other substances. Patient will reach out to their support network.