Progress Note for Inpatients

Background: - Duration of admission thus far: 7 days - Legal status of the patient: Sectioned under the Mental Health Act - Demographics: [45-year-old male], married, employed as a software engineer, income from employment, lives with his wife and two children, receiving support from the Crisis Resolution Home Treatment Team. - Diagnosis: Major Depressive Disorder, Recurrent, Severe; Anxiety Disorder, Generalised; Alcohol Use Disorder, in remission. - Treatment: Sertraline 100mg daily, Quetiapine 100mg at night, Lorazepam 1mg as required for anxiety. Progress: - Current issues: Patient reports persistent low mood, anhedonia, and difficulty sleeping. Reports feeling overwhelmed by work and family responsibilities. Expresses feelings of hopelessness and worthlessness. Reports increased anxiety, particularly in social situations. Denies suicidal ideation or intent. - Neurovegetative symptoms: Sleep is disturbed, with difficulty falling asleep and early morning wakening. Appetite is reduced. Energy levels are low. Overall function is impaired. - Mood and anxiety symptoms: Mood is depressed. Reports frequent feelings of anxiety and worry. Denies psychotic symptoms. - Response to treatments: Sertraline has provided some benefit, but symptoms remain significant. Quetiapine is helping with sleep. No significant side effects reported. Review of EMR: - Nursing notes indicate patient is cooperative and engaging in therapeutic activities. No concerning behaviours noted. Mental State Examination: - Appearance: Well-groomed, appears his stated age. - Behaviour: Cooperative and engaged in the interview. - Cooperation: Cooperative. - Mood: Depressed. - Affect: Restricted. - Speech: Normal rate and rhythm. - Thought form: Linear and goal-directed. - Thought content: Reports feelings of worthlessness and hopelessness. No delusions or obsessions. - Cognition: Alert and oriented to person, place, and time. - Insight: Has some insight into his illness. - Judgement: Appears to have intact judgement. - Risk: No current risk to self or others. Physical Findings: - Vital signs: BP 130/80, HR 78, RR 16, Temp 37.0 Risk: - No current risk to self or others. Background risk remains elevated due to history of suicidal ideation. Impression: - Progress since the last review: Minimal improvement since admission. - Clinical impressions: Major Depressive Disorder, Recurrent, Severe, with persistent symptoms despite current treatment. - Main issues identified during this review: Persistent low mood, anxiety, and sleep disturbance. Plan: - Nursing observations required: 1 (constant). - Treatment plan: Continue Sertraline 100mg daily, increase Quetiapine to 150mg at night. Continue Lorazepam 1mg as needed for anxiety. Referral to group therapy for CBT. - Follow-up plans and appointments: Review in one week. - Patient education and counseling: Continue to provide education about depression and anxiety. Encourage participation in therapy and medication adherence.