HPI:
- The patient, a 45-year-old male, presents with ongoing feelings of sadness and lack of motivation, which have persisted for the past three months. He reports difficulty concentrating at work and a lack of interest in activities he once enjoyed. The patient has a history of depression and anxiety, previously managed with medication and therapy.
- Past medical history includes hypertension and a previous appendectomy.
- Current medications include Sertraline 50mg daily and Lisinopril 10mg daily. The patient also takes a daily multivitamin.
- The patient is a non-smoker, consumes alcohol socially, and exercises regularly.
- No known allergies.
Psychiatric Review of Symptoms:
- The patient reports a persistent low mood and feelings of hopelessness.
- He experiences frequent anxiety, particularly in social situations.
- No psychotic symptoms reported.
- Cognitive symptoms include difficulty concentrating and forgetfulness.
- The patient reports difficulty falling asleep and frequent waking during the night.
- Appetite has decreased, resulting in a 5-pound weight loss over the past month.
- No other psychiatric symptoms reported.
Mental Status Exam:
- The patient appears well-groomed but with a flat affect.
- Speech is normal in rate and volume.
- Mood is described as "down" and affect is congruent with mood.
- Thought process is logical and coherent.
- Thought content is free of delusions or hallucinations.
- Perception is normal.
- Cognition is intact, but the patient reports subjective memory difficulties.
- Insight and judgment are fair.
Treatment Plan:
Medication Changes:
- Increase Sertraline to 100mg daily to address persistent depressive symptoms.
Psychotherapy:
- Continue with cognitive-behavioral therapy sessions weekly.
Patient Education:
- Discussed the importance of medication adherence and lifestyle modifications, including regular exercise and a balanced diet.
Follow-Up:
- Follow-up appointment scheduled in four weeks to assess response to medication adjustment and therapy progress.
