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.
Chief Complaints
[Main presenting issue] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet point format.)
Demographics
(Living status, employment status, current relationship status, any children) (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
History of Presenting Complaints
[Describe current issues with all available details, reasons for visit, complete history of presenting complaints] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
[Describe any other associated symptoms with details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Past Psychiatric History
[Describe past psychiatric diagnoses, treatments, hospitalisations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
[List current medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
Medical History
[List chronic medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
Family History
[Note any psychiatric illnesses within the family, specifying relationship and nature of illnesses] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Substance History
[Substance use such as smoking, alcohol, recreational drugs] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Social and Developmental History
[Social support] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
(Birth, earlier development, attachments, primary school and high school details, relationships with teachers and other students, drugs and alcohol use, abuse or trauma, school completions, higher studies, employment history and relationships with children) (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
(Employment history) (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Mental Status Examination
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Behaviour: [Observe the patient's activity level, interaction with surroundings, and any notable behaviors] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Mood: [Record the patient's self-described emotional state] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Affect: [Describe the range and appropriateness of the patient's emotional responses] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Thoughts: [Assess thought process and content, noting any distortions, delusions, or preoccupations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Perceptions: [Note any reported hallucinations or sensory misinterpretations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Cognition: [Describe memory, orientation, concentration, comprehension] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Insight: [Describe the patient's understanding of their condition] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- Judgment: [Describe decision-making ability and understanding of consequences] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Risk Assessment
[Suicidality, homicidality, other risks] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Diagnosis
[DSM-5 criteria, psychological scales/questionnaires used] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Treatment Plan
[Investigations] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
[Medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
[Psychotherapy] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
[Family meetings, collateral information, psychosocial interventions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
[Follow-up appointments and referrals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
Safety Plan
[Steps to take in crisis, support contacts or strategies for safety] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include 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.)
