Problem:
Write a follow up psych progress note on this same patient creating a scenario to add to this previous visit note to show stability and no changes at this time
Chief Complaint(s): "Excessive spending and irrational decisions affecting my academics" History of Present Illness (HPI): Patient is a 20-year-old female with a known history of depression and bipolar disorder. She presents with increased instances of impulsive behavior, characterized by excessive spending and making irrational decisions that have started to impact her academic performance negatively. Over the past month, the patient has engaged in frequent shopping sprees, maxing out credit cards, and has been impulsively making decisions without considering the consequences. She reports feeling euphoric at times but also experiences moments of intense sadness. These mood fluctuations have led to difficulties in concentrating on her studies, leading to a decline in her academic performance. Her mother accompanies her today, expressing concern about the patient's erratic spending habits and their financial impact. Despite being on medication, the patient feels her symptoms are not well-controlled. Past Medical History (PMH): None reported Psychiatric History: Depression Bipolar disorder Current Medications: Lamotrigine (Lamictal) 100 mg PO daily Fluoxetine (Prozac) 20 mg PO daily Allergies/Intolerances: No known drug allergies (NKDA) Family History: Mother with anxiety disorder Father with history of bipolar disorder Social History: Single, lives on campus Undergraduate student Denies alcohol or drug use Enjoys socializing with friends and engaging in student activities Assessment: Patient presents as alert and oriented to person, place, time, and situation. She is casually dressed and participates actively in the session. Her affect is broad and mood is noted to be labile, shifting from elevated to despondent during the session. She acknowledges the episodes of excessive spending and decision making without foresight. No evidence of hallucinations or delusions is present, and she denies suicidal or homicidal ideations.
Treatment/Plan: Increase Lamotrigine (Lamictal) to 150 mg PO daily to better stabilize mood Continue Fluoxetine (Prozac) 20 mg PO daily, monitor for any side effects Monitoring and Support: Monitor for reductions in impulsive behaviors and mood stability Regular follow-up to assess medication effectiveness and side effect profile Therapeutic Recommendations: Recommendation for cognitive-behavioral therapy (CBT) to address impulsive behaviors and decision-making skills Encouraged budgeting tools and financial counseling to manage spending habits Advocated for a consistent daily schedule to promote better academic focus Continue regular therapy sessions; next scheduled in 7 days Follow-up appointment in 2 weeks to evaluate the response to medication adjustments and behavioral interventions. Need Assignment Help?