Psychiatry Follow Up

Clinical Update: On 1 November 2024, the patient presented for a follow-up session. The patient reported continued struggles with low mood and anxiety, particularly during social situations. They are currently taking Sertraline 100mg daily, which seems to be providing some relief, although the patient still experiences occasional panic attacks. Sleep has improved slightly, with the patient now averaging 6-7 hours of sleep per night. Self-care routines are inconsistent, and the patient admits to infrequent exercise. Social engagement remains limited, and the patient denies any substance use. The patient's mood is generally low, with frequent feelings of sadness and worry. Anxiety symptoms include racing thoughts and physical sensations such as a racing heart. No screening results for other psychiatric conditions were mentioned. Mental Status Exam: The patient was alert and cooperative during the session. Their mood was low, and their affect was constricted. Thought process was linear, and thought content revealed themes of worry and self-doubt. Speech was normal in rate and rhythm. No perceptual disturbances were reported. Cognitive function appeared intact. The patient demonstrated some insight into their condition but struggled with judgment in social situations. No suicidal ideation was expressed. Diagnostic Impression: Major Depressive Disorder, Moderate, and Generalised Anxiety Disorder. The primary diagnosis is based on the patient's persistent low mood, loss of interest, and excessive worry. Medication Recommendations: The current dosage of Sertraline 100mg daily will be maintained. The patient was advised to continue taking the medication as prescribed and to report any side effects. Additional Treatment Recommendations: The patient was encouraged to continue with their existing therapy sessions. A referral to a support group for anxiety was provided. Lifestyle and Self-Care: The patient was encouraged to establish a regular sleep schedule, incorporate daily exercise, and practice mindfulness techniques to manage anxiety. Patient Understanding and Agreement: The patient demonstrated a good understanding of their diagnoses and treatment plan and agreed to continue with the recommended interventions. Follow-Up: The patient is scheduled for a follow-up appointment in four weeks, via telehealth.