Update notes for OneNote records

[Document date of appointment 01/11/2024] **Diagnosis** - Major Depressive Disorder, Recurrent, Severe, with Psychotic Features - Generalised Anxiety Disorder - Social Anxiety Disorder **Medications** - Sertraline 200mg daily - Quetiapine 300mg at night - Clonazepam 0.5mg as needed for anxiety 1. Issue, problem or request 1 (include issue, request or condition name only) - Major Depressive Disorder, Recurrent, Severe, with Psychotic Features - Current issues, reasons for visit, history of presenting complaints etc relevant to issue 1 (include only if applicable) - Patient reports worsening low mood, anhedonia, and fatigue over the past week. - Reports auditory hallucinations, including voices telling her she is worthless. - Expresses suicidal ideation with a plan. - Past medical history, previous surgeries, medications, relevant to issue 1 (include only if applicable) - History of multiple previous depressive episodes. - No previous suicide attempts. - Currently taking Sertraline and Quetiapine. - Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 1 (include only if applicable) - Vitals: BP 130/80, HR 88, RR 16, Temp 37.0°C. - Mental State Examination: Appearance: dishevelled, tearful. Mood: depressed. Affect: constricted. Thought process: linear, coherent, but with delusional content. Thought content: delusions of worthlessness, suicidal ideation. Perceptions: auditory hallucinations. Insight and judgment: poor. 2. Issue, problem or request 2 (include issue, request or condition name only) - Generalised Anxiety Disorder - Current issues, reasons for visit, history of presenting complaints etc relevant to issue 2 (include only if applicable) - Patient reports persistent worry about various aspects of her life, including finances, health, and relationships. - Reports difficulty sleeping due to racing thoughts. - Reports feeling restless and on edge. - Past medical history, previous surgeries, medications, relevant to issue 2 (include only if applicable) - History of anxiety symptoms for several years. - Currently taking Clonazepam as needed. - Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 2 (include only if applicable) - Mental State Examination: Anxious appearance. Speech: pressured. Thought process: racing. 3. Issue, problem or request 3, 4, 5 etc (include issue, request or condition name only) - Social Anxiety Disorder - Current issues, reasons for visit, history of presenting complaints etc relevant to issue 3, 4, 5 etc (include only if applicable) - Patient reports significant distress in social situations. - Avoids social gatherings and interactions. - Reports fear of being judged or embarrassed. - Current issues can include psychosocial concerns (Elaborate on issues such as workplace stressors, interpersonal stressors, financial concerns, and any social issues that are impacting on her mental or physical health. Detail the issues involved. Use patient quotes) - Patient reports feeling isolated and lonely. "I just can't seem to connect with people anymore." She is experiencing significant financial stress due to job loss and is worried about eviction. She is also struggling with interpersonal conflicts with her family. - Past medical history, previous surgeries, medications, relevant to issue 3, 4, 5 etc (include only if applicable) - No relevant past medical history. - Objective findings, vitals, physical or mental state examination findings, including system specific examination(s) for issue 3, 4, 5 etc (include only if applicable) - Mental State Examination: Anxious appearance, avoids eye contact. 4. Issue related to Social and Functional Status (Discuss the patient's social relationships and their level of function in daily activities. Include information about their relationship with significant others, their participation in programs like NDIS, workplace issues, performance or conflicts, social activities, and their ability to manage household duties. If the patient receives help from others, such as a spouse or partner or family, describe this support.) - Patient lives alone. She has limited contact with family and friends. She is currently unemployed and struggling to manage household duties. She is not currently participating in any social programs. **Plan and recommendations** 1. Increase Quetiapine to 400mg at night. 2. Review Sertraline dosage in two weeks. 3. Continue Clonazepam as needed. 4. Referral to crisis team for immediate support. 5. Referral to a psychologist for Cognitive Behavioral Therapy (CBT). 6. Encourage patient to attend support groups. - Investigations planned for Issue 1, 2, 3, 4, 5 etc (include only if applicable) - None at this time. - Treatment planned for Issue 1, 2, 3, 4, 5 etc (include only if applicable) - Medication management. - Psychotherapy. - Relevant referrals for Issue 3, 4, 5 etc (include only if applicable) - Crisis team. - Psychologist. - detail time planned for next follow up appointment - Follow up appointment in one week.