Scribe BC - Psychiatry Progress Note

**INTERIM HISTORY** Patient presents today for a follow-up appointment to discuss ongoing symptoms of anxiety and depression. The patient reports feeling increasingly overwhelmed and experiencing difficulty sleeping. The symptoms have been present for approximately 6 months, with a gradual onset. The patient reports feeling anxious most days, with periods of feeling down and hopeless. The patient reports that the symptoms are worse in the evenings and on weekends. The patient reports that the symptoms are triggered by work-related stress and social situations. The patient reports that they have tried over-the-counter sleep aids, which have provided minimal relief. The patient reports a previous episode of depression 2 years ago, which was treated with medication and therapy. The patient reports that the symptoms are impacting their ability to concentrate at work and maintain social relationships. The patient reports associated symptoms of fatigue, loss of appetite, and irritability. **MENTAL STATUS EXAMINATION** The patient appears their stated age and is well-groomed. The patient reports feeling anxious and down. The patient's affect is constricted, and their mood is congruent with their reported feelings. The patient's thought process is linear and goal-directed, with no evidence of thought disorder. The patient denies any hallucinations or delusions. The patient demonstrates good insight into their condition and acknowledges the need for treatment. The patient demonstrates good decision-making ability and understands the consequences of their actions. The patient's memory, orientation to time/place/person, concentration, and comprehension are intact, however, not formally assessed. **PHYSICAL EXAMINATION** A physical examination was conducted with the following vitals recorded: Height: 175cm Weight: 75KG HR: 78 BPM BP: 120/80 SpO2: 98% on room air **INVESTIGATIONS** No investigations were ordered at this time. **IMPRESSION** Major Depressive Disorder, moderate severity, and Generalized Anxiety Disorder. The patient's condition has remained stable since the last visit. **PLAN** Medication review and adjustment. Continuation of psychotherapy. Schedule a follow-up appointment in 4 weeks. Next appointment date for psychiatric follow-up: 1 December 2024 "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."