**INTERIM HISTORY**
Patient presents today for a follow-up appointment to discuss ongoing symptoms of anxiety and depression. The patient reports feeling increasingly overwhelmed and experiencing difficulty sleeping. The symptoms have been present for approximately 6 months, with a gradual onset. The patient reports feeling anxious most days, with periods of feeling down and hopeless. The patient reports that the symptoms are worse in the evenings and on weekends. The patient reports that the symptoms are triggered by work-related stress and social situations. The patient reports that they have tried over-the-counter sleep aids, which have provided minimal relief. The patient reports a previous episode of depression 2 years ago, which was treated with medication and therapy. The patient reports that the symptoms are impacting their ability to concentrate at work and maintain social relationships. The patient reports associated symptoms of fatigue, loss of appetite, and irritability.
**MENTAL STATUS EXAMINATION**
The patient appears their stated age and is well-groomed. The patient reports feeling anxious and down. The patient's affect is constricted, and their mood is congruent with their reported feelings. The patient's thought process is linear and goal-directed, with no evidence of thought disorder. The patient denies any hallucinations or delusions. The patient demonstrates good insight into their condition and acknowledges the need for treatment. The patient demonstrates good decision-making ability and understands the consequences of their actions. The patient's memory, orientation to time/place/person, concentration, and comprehension are intact, however, not formally assessed.
**PHYSICAL EXAMINATION**
A physical examination was conducted with the following vitals recorded:
Height: 175cm
Weight: 75KG
HR: 78 BPM
BP: 120/80
SpO2: 98% on room air
**INVESTIGATIONS**
No investigations were ordered at this time.
**IMPRESSION**
Major Depressive Disorder, moderate severity, and Generalized Anxiety Disorder. The patient's condition has remained stable since the last visit.
**PLAN**
Medication review and adjustment.
Continuation of psychotherapy.
Schedule a follow-up appointment in 4 weeks.
Next appointment date for psychiatric follow-up: 1 December 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."
**INTERIM HISTORY**
(provide in paragraph format, no bullet points)
[Mention reasons for visit, chief complaints such as requests, symptoms etc] [Mention Duration/timing/location/quality/severity/context of complaint] [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] [Progression: Mention describe how the symptoms have changed or evolved over time] [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.)
**MENTAL STATUS EXAMINATION**
(provide in paragraph format, no bullet points)
[Record the patient's physical apperance and self-described emotional state, using their own words if possible.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the placeholder completely.) [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the placeholder completely.) [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the placeholder completely.) [If reported, Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient. If none note "no observed perceptual disturbances"] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the placeholder completely.)
[Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the placeholder completely.) [Describe the patient's decision-making ability and understanding of the consequences of their actions.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the placeholder completely.) [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension and specify "however, not formally assessed".] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit the placeholder completely.)
**PHYSICAL EXAMINATION**
(provide in paragraph format, no bullet points)
A physical examination was conducted with the following vitals recorded:
Height: [insert height in numeric format with cm unit](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.)Weight: [insert with in numeric format with KG unit](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.)HR: [insert heart rate in numeric format with BPM unit](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.)BP: [systolic/diastolic in numeric format](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.)SpO2: [insert in numeric format with percentage and specify on room air] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any placeholder that's not mentioned.)
**INVESTIGATIONS**
(provide in paragraph format, no bullet points)
[Investigations with results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
**IMPRESSION**
(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; omit any placeholder that's not mentioned.)
**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.)
