[Practitioner's Full Name and Title]
Dr. Eleanor Vance
CONSULTANT PSYCHIATRIST
1 November 2024
,Diagnosis:,
* Major Depressive Disorder, recurrent, severe, with psychotic features
* Generalised Anxiety Disorder
,Medications:,
* Sertraline 100mg daily
* Quetiapine 100mg nocte
Thank you once for your ongoing referral for me to see John who presents today to see me for ongoing management of his mental health.
John is a 38-year-old married man who lives with his wife and two children. He has been experiencing significant difficulties with his mood and anxiety over the past year.
John presented to the clinic today looking dishevelled and withdrawn. He was accompanied by his wife, who provided additional context to his presentation. He made minimal eye contact and spoke in a quiet, monotone voice. He appeared to be somewhat agitated, wringing his hands throughout the consultation.
John reports a persistent low mood, with feelings of worthlessness and hopelessness. He states, "I feel like I'm a burden to everyone." He has experienced significant changes in his sleep, appetite, and energy levels. He reports sleeping for 10-12 hours a night but still feeling exhausted. He has a poor appetite and has lost weight unintentionally. He has also reported suicidal ideation, stating, "I don't see the point in going on." He denies any current suicidal plan or intent. He also reports significant worry and anxiety, particularly about his finances and his health. He reports feeling restless and unable to concentrate. He has also reported panic attacks.
John's depression has been treated with Sertraline 100mg daily, which has provided some benefit, but his mood remains significantly low. He has also been prescribed Quetiapine 100mg nocte for his psychotic symptoms and sleep. He reports that the medication has helped with his sleep, but he still experiences auditory hallucinations. He has been attending weekly psychotherapy sessions, which he finds helpful. I have advised increasing the Sertraline to 150mg daily and continuing with his current psychotherapy. I have also advised him to seek support from his family and friends.
John's social and functional status has been significantly impacted by his mental health. He has withdrawn from social activities and has difficulty maintaining his work. He is currently on sick leave from his job. His wife provides significant support, helping with household duties and childcare. He is not currently receiving any support from NDIS.
John has no significant physical health issues.
On review of his recent investigation results [01/10/2024], I noted the following:
* FBC: Within normal limits.
* U&Es: Within normal limits.
* LFTs: Within normal limits.
Hence, at the conclusion of this appointment, my intentions for further management include the following:
1. Increase Sertraline to 150mg daily.
2. Continue with current psychotherapy.
3. Encourage John to attend a support group.
4. Schedule a follow-up appointment in four weeks to monitor his progress.
I have advised John to continue taking his medications as prescribed and to attend his psychotherapy sessions. I have also encouraged him to reach out to his support network and to contact me if his symptoms worsen. I have also advised him to maintain a healthy lifestyle, including regular exercise and a balanced diet.
Thank you once again for referring John to see me and I will keep you informed of his progress.
Dr. Eleanor Vance
Consultant Psychiatrist
