Psychiatry Ward Review Inpatient

Meeting Type: Ward Round Mental Health Act Status: Section 2 When does Section expire: 03/11/2024 Present: Dr. Emily Carter (Consultant Psychiatrist), Nurse Jones, Patient: John Smith Diagnosis: F32.1 - Moderate depressive episode Medications: - Sertraline 100mg daily - Lorazepam 1mg as required History of Presenting Complaints: - The patient reports low mood, anhedonia, and poor sleep for the past three months. He expresses feelings of hopelessness and worthlessness. He has been experiencing suicidal ideation, but denies any active plans or intent. He reports a loss of appetite and a 10kg weight loss. - Associated symptoms include fatigue, difficulty concentrating, and social withdrawal. Past Medical & Psychiatric History: - Diagnosed with Major Depressive Disorder five years ago. Previous episodes treated with medication and psychotherapy. One previous hospitalisation for a suicide attempt. - No chronic medical conditions. Family History: - Mother has a history of recurrent depression. Social History: - Unemployed, previously worked as a teacher. Completed a Master's degree. - Smokes 10 cigarettes per day. - Limited social support; lives alone. Meeting notes: Dr. Carter reviewed Mr. Smith's progress. Mr. Smith stated, "I still feel down most days, but I'm trying to engage in the activities we discussed." Nurse Jones reported that Mr. Smith has been attending group therapy sessions and is compliant with his medication. Dr. Carter noted that the patient's mood has slightly improved since admission, but suicidal ideation persists. She stated, "We need to closely monitor his risk and adjust his treatment plan as needed." The patient agreed to continue with the current treatment plan. Mental Status Examination: - Appearance: Appears his stated age, well-kempt but with a slightly unkempt appearance. Clothing is appropriate for the setting. - Behaviour: Psychomotor retardation observed. Slow movements and speech. - Speech: Slow, soft volume, and monosyllabic. - Mood: Reports feeling "down" and "hopeless." - Affect: Restricted affect; congruent with reported mood. - Thoughts: Preoccupied with negative thoughts and feelings of worthlessness. Reports suicidal ideation. - Perceptions: No hallucinations reported. - Cognition: Oriented to time, place, and person. Concentration is slightly impaired. - Insight: Acknowledges having a mental health problem and understands the need for treatment. - Judgment: Judgment appears impaired due to the severity of his depression. Risk Assessment: - Moderate risk of suicide due to persistent suicidal ideation and previous attempt. No current plans or intent. Diagnosis: - F32.1 - Moderate depressive episode. Based on DSM-5 criteria, the patient meets the criteria for a moderate depressive episode. Formulation: The patient's current presentation is likely due to a combination of biological vulnerability, psychosocial stressors, and lack of social support. Treatment Plan: - Continue Sertraline 100mg daily. - Continue Lorazepam 1mg as required for anxiety. - Increase frequency of individual therapy sessions to twice per week. - Continue group therapy. - Review medication in one week. - Refer to occupational therapy for vocational support. - Family meeting planned for next week. - Follow-up appointment in one week. Safety Plan: - Contact crisis team if suicidal thoughts worsen. - Identify coping strategies to manage distress. - Contact a friend or family member for support. - Remove access to means of self-harm.