PSYCHIATRY CASE REVIEW NOTE
(from context, pull patient name, date of birth and health services number note in same format)(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
**SUMMARY**
Patient is a 35-year-old male with a history of Major Depressive Disorder, currently experiencing a worsening of depressive symptoms. He reports increased anhedonia, fatigue, and difficulty concentrating. The patient's suicidal ideation has increased in frequency and intensity. Differential diagnoses include bipolar disorder and treatment-resistant depression.
**PLAN**
Investigations planned:
* Complete blood count (CBC) and comprehensive metabolic panel (CMP) to rule out any underlying medical conditions.
* Thyroid function tests (TFTs) to assess for hypothyroidism.
* Review of current medication list and potential interactions.
Treatment planned:
* Increase dosage of current antidepressant medication.
* Initiate a trial of a second antidepressant medication.
* Referral to a therapist for cognitive behavioural therapy (CBT).
* Close monitoring of suicidal ideation and risk assessment.
Relevant other actions such as counselling, referrals etc:
* Referral to a psychiatrist for a second opinion.
* Contact patient's family to discuss safety plan.
Next appointment date for psychiatric follow-up: 15 November 2024
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
Psychiatry
PSYCHIATRY CASE REVIEW NOTE
(from context, pull patient name, date of birth and health services number note in same format)(Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
**SUMMARY**
(provide in paragraph format, no bullet points)
[Mention likely diagnosis and change in status or stability since last visit] [Differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
**PLAN**
(point form with no bullet points)
[Investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
[Treatment planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
[Relevant other actions such as counselling, referrals etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
[Next appointment date for psychiatric follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Psychiatry