Background:
Patient is a [35]-year-old male presenting for follow-up.
On Review:
Patient reports feeling increasingly anxious and experiencing difficulty sleeping. He describes feeling overwhelmed by work and financial stressors. He reports feeling hopeless and has been isolating himself from friends and family.
"I feel like I'm drowning," he stated. "Everything feels like too much."
Psychotic Screen:
No auditory or visual hallucinations reported.
Neuro-Vegetative Screen:
Mood: Depressed.
Sleep: Difficulty falling asleep and staying asleep.
Appetite: Decreased appetite.
Energy: Low energy levels.
Motivation: Reduced motivation.
Memory/Focus: Difficulty concentrating.
Past Psychiatric History:
Patient has a history of major depressive disorder, diagnosed five years ago. He was previously treated with sertraline, which was discontinued due to side effects.
Social History:
Patient is employed as a software engineer. He is single and lives alone. He has limited social support.
Medical History:
Patient has no significant medical history.
Medication History:
Patient is not currently taking any medications.
AODS History:
Patient reports occasional alcohol use, but denies any substance use disorder.
Forensic History:
No forensic history.
Family History:
Mother has a history of anxiety.
MSE:
Appearance and Behaviour: Appears his stated age, well-groomed, and cooperative. He is restless and fidgety.
S: Speech is normal rate and rhythm.
M and A: Mood is depressed. Affect is constricted.
T: Thought process is linear and goal-directed.
P: No perceptual disturbances.
I: Patient acknowledges his current difficulties.
J: Judgment is intact.
C: Cognition is intact.
Risk Assessment:
Patient denies suicidal ideation or homicidal ideation. He reports feeling hopeless but denies any plans for self-harm.
Impression:
Major Depressive Disorder, moderate severity.
Plan:
Initiate escitalopram 10mg daily. Schedule follow-up appointment in four weeks. Provide patient with psychoeducation about depression and its treatment. Recommend cognitive behavioural therapy (CBT).
Background:
[describe background information] (only include describe background information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
On Review:
[describe findings on review] (only include describe findings on review if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[include patient description of symptoms and general conversation here if they do not fit in other headings]
[Include verbatim feelings and cognitions here]
Psychotic Screen:
[Auditory Hallucinations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Visual Hallucinations] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Paranoia] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Thought Insertion/Thought Withdrawal/Thought Broadcast] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Delusions of Reference] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Passivity Phenomenon] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Neuro-Vegetative Screen:
[Mood] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Sleep] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Appetite] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Energy] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Motivation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Memory/Focus] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Past Psychiatric History:
[describe past psychiatric history] (only include describe past psychiatric history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Social History:
[describe social history] (only include describe social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medical History:
[describe medical history] (only include describe medical history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medication History:
[mention medications and herbal supplements] (only include mention medications and herbal supplements if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
AODS History:
[describe alcohol and other drug use history] (only include describe alcohol and other drug use history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Forensic History:
[describe forensic history] (only include describe forensic history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Family History:
[describe family history] (only include describe family history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Background:
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MSE:
Appearance and Behaviour:
[describe appearance] (only include describe appearance if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
S:
[describe speech] (only include describe speech if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
M and A:
[describe mood and affect] (only include describe mood and affect if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
T:
[describe thought process] (only include describe thought process if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
P:
[describe perception] (only include describe perception if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
I:
[describe insight] (only include describe insight if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
J:
[describe judgment] (only include describe judgment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
C:
[describe cognition] (only include describe cognition if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Risk Assessment:
[describe risk assessment] (only include describe risk assessment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Impression:
[describe impression] (only include describe impression if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Plan:
[describe plan] (only include describe plan 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, 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.)
