Psychiatrist's note (custom)
History of Presenting Complaints:
- The patient, a 35-year-old male, presents with worsening symptoms of anxiety and low mood over the past three months. He reports feeling overwhelmed at work, difficulty sleeping, and a loss of interest in activities he previously enjoyed. He also describes experiencing panic attacks, characterised by heart palpitations, shortness of breath, and a sense of impending doom. The patient reports that these symptoms have significantly impacted his ability to function at work and in his personal life. He reports that he has been feeling increasingly isolated and withdrawn from friends and family.
- The patient also reports associated symptoms of fatigue, poor appetite, and difficulty concentrating.
Past Medical & Psychiatric History:
- The patient was previously diagnosed with Generalized Anxiety Disorder (GAD) five years ago and was treated with Cognitive Behavioral Therapy (CBT). He reports that the CBT was helpful initially, but the benefits have waned over time. He has no history of hospitalizations.
- The patient has no chronic medical conditions.
Medications:
- The patient is currently taking Sertraline 50mg daily, prescribed three years ago. He reports good compliance with his medication.
Family History:
- The patient's mother has a history of depression, for which she takes medication.
Social History:
- The patient is employed as a software engineer and has a master's degree. He reports feeling stressed at work due to increasing demands and deadlines.
- The patient reports smoking 10 cigarettes per day and drinks alcohol socially, approximately once a week.
- The patient has a supportive network of friends and family, but feels increasingly isolated due to his symptoms.
Mental Status Examination:
- Appearance: The patient is well-groomed and dressed in casual attire. He appears his stated age.
- Behaviour: The patient is restless and fidgety, with frequent hand movements. He makes good eye contact but appears anxious.
- Speech: The patient's speech is of normal rate and volume, but he speaks with some hesitancy.
- Mood: The patient reports feeling 'anxious' and 'down'.
- Affect: The patient's affect is congruent with his stated mood, showing a range of emotions, but appearing somewhat constricted.
- Thoughts: The patient's thought process is linear and goal-directed. He denies any suicidal ideation, homicidal ideation, or psychotic symptoms. He reports intrusive thoughts related to his work and health.
- Perceptions: The patient denies any hallucinations or perceptual disturbances.
- Cognition: The patient is alert and oriented to person, place, and time. His memory is intact. He demonstrates good concentration during the interview.
- Insight: The patient acknowledges that he is experiencing symptoms of anxiety and depression and recognizes the need for treatment.
- Judgment: The patient demonstrates good judgment and understands the consequences of his actions.
Risk Assessment:
- The patient denies suicidal or homicidal ideation. He has no plans or intent to harm himself or others. He has access to firearms, but states he has no intention of using them to harm himself or others.
Diagnosis:
- Major Depressive Disorder, Recurrent, Moderate. Generalized Anxiety Disorder.
Treatment Plan:
- Planned investigations: No investigations are planned at this time.
- Medication plans including changes, continuing medicatins, prescriptions, medications ceased or any other medication related plans: Continue Sertraline 50mg daily. Increase Sertraline to 100mg daily in two weeks if symptoms do not improve. Prescribe a short course of Lorazepam 0.5mg as needed for acute anxiety symptoms.
- Psychotherapy plans and strategies: Recommend individual CBT sessions to address anxiety and depressive symptoms. Explore the use of mindfulness techniques.
- Planned family meetings & collateral information, psychosocial interventions: Encourage the patient to engage in social activities and maintain contact with his support network.
- Follow-up appointments and referrals: Schedule a follow-up appointment in four weeks to assess the patient's response to treatment. Refer the patient to a therapist for CBT.
Safety Plan:
- The patient has identified his support network and will contact them if he experiences worsening symptoms. He will also call the crisis hotline if needed. He will remove access to firearms if his mental health deteriorates.
History of Presenting Complaints:
- [Describe current issues with all available details, reasons for visit, and complete history of presenting complaints.] (Only include if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Describe any other associated symptoms with details.] (Only include [associated symptoms with details] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Past Medical & Psychiatric History:
- [Describe past psychiatric diagnoses, treatments, hospitalizations.] (Only include [past psychiatric diagnoses, treatments, hospitalizations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [List chronic medical conditions.] (Only include [chronic medical conditions] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Medications:
- [List current and past medications if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Family History:
- [Note any psychiatric illnesses within the family, specifying the relationship to the patient and the nature of the illnesses.] (Only include [psychiatric illnesses within the family] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Social History:
- [Occupation, level of education.] (Only include [occupation and level of education] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Substance use such as smoking, alcohol, recreational drugs.] (Only include [substance use such as smoking, alcohol, recreational drugs] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Social support.] (Only include [social support] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Mental Status Examination:
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics.] (Only include appearance details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors.] (Only include behaviour details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech.] (Only include speech characteristics if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Mood: [Record the patient's self-described emotional state, using their own words if possible.] (Only include self-described emotional state if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood.] (Only include [emotional response] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations.] (Only include thought process and content if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient.] (Only include perception details if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension.] (Only include cognitive observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial.] (Only include insight observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions.] (Only include judgement observations if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Risk Assessment:
- [Assessment of uicidality, homicidality, and other risks.] (Only include [Assessment of suicidality, homicidality, other risks] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Diagnosis:
- [Insert the diagnosis, relevant DSM-5 criteria, psychological scales/questionnaires.] (Only include diagnosis details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Treatment Plan:
- [Planned investigations.] (Only include [investigations] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Medication plans including changes, continuing medicatins, prescriptions, medications ceased or any other medication related plans.] (Only include medication plans if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Psychotherapy plans and strategies.] (Only include psychotherapy plans if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Planned family meetings & collateral information, psychosocial interventions.] (Only include family meetings and psychosocial interventions if they have been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Follow-up appointments and referrals.] (Only include follow-up plans and referrals if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Safety Plan:
- [Detail safety plan including steps to take in crisis.] (Only include safety plan details if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
(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 that the information has not been explicitly mentioned in your output—just leave the relevant placeholder or omit it completely. Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)
