Miwatj Review template

Psychiatrist Review Date: 1 November 2024 Location: Telehealth Present (list participants): Dr. Anya Sharma (Child and Adolescent Psychiatrist), Patient (Liam, 16 years old), Mother (Sarah) Patient background: Liam is a 16-year-old male presenting for a review of his mental health. He lives at home with his mother and father. He is currently attending school and is in year 11. Collateral history was received from his mother, who reports that Liam has been experiencing increased anxiety and low mood over the past month. Previous diagnoses: * Major Depressive Disorder, moderate severity * Generalised Anxiety Disorder, moderate severity Medical history: Nil significant medical history. Current medications: * Sertraline 100mg daily * Quetiapine 25mg at night Previous medications: * Fluoxetine - ceased due to side effects of increased anxiety. Objective: - Vital signs: Heart rate 78 bpm, Blood pressure 120/80 mmHg, Weight 65kg, Height 170cm. - Collateral history: Mother reports Liam has been isolating more, struggling with school work, and has had several panic attacks in the last month. Review: Liam was reviewed via telehealth with his mother for a routine follow-up. This is on a background of Major Depressive Disorder and Generalised Anxiety Disorder. Liam is currently attending school but is finding it difficult to concentrate. He reports feeling overwhelmed by school work and social pressures. He reports feeling low mood most days and has had several panic attacks in the last month. He reports that he has been sleeping more than usual and has lost interest in activities he used to enjoy. He reports that he has been feeling more anxious and worried about things. Liam reports that he has been taking his medication as prescribed and has not missed any doses. He reports that he has experienced some side effects from the medication, including drowsiness and dry mouth. Mental state: Liam presented as a well-groomed, cooperative young man. His mood was low, and his affect was constricted. He reported feeling anxious and worried. His thought processes were linear and goal-directed. He denied any suicidal ideation or self-harm. His insight and judgment appeared intact. Impression: Liam's presentation is consistent with a diagnosis of Major Depressive Disorder and Generalised Anxiety Disorder. His symptoms have worsened in the last month. His response to current treatment has been partial. His overall functioning has been impacted by his symptoms. Today we discussed: * Liam's current symptoms and medication side effects. * The need to increase the dose of Sertraline. * The need to continue with therapy. Recommendations: 1. Please increase Sertraline to 150mg daily. 2. Please continue with weekly therapy sessions. 3. Please schedule a follow-up appointment in four weeks to review progress. Dr. Anya Sharma MBBS, FRANZCP