Problem:
Write a follow up psych progress note on this patient creating a scenario to result the increase in her medication and a follow up in 2 weeks Maintain this template.
Chief Complaint(s): Follow up for Medication monitoring and management
History of Present Illness (HPI): Patient is a 14-year-old male with history of Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD). He presents today for follow-up regarding medication monitoring and management. According to his mother, patient continues to experience symptoms of PTSD, most notably intrusive thoughts and flashbacks related to a traumatic event he witnessed approximately two years ago. These symptoms have affected his school performance and social interactions. He reports feeling sad and hopeless most days, accompanied by frequent crying spells. His appetite has decreased, and he has lost several pounds since his last visit. Sleep remains fragmented, with difficulty falling and staying asleep, often due to nightmares. Though he denies current suicidal ideation or self-harming behaviors, he acknowledges fleeting passive thoughts of worthlessness. Patient is actively engaged in cognitive behavioral therapy (CBT), which he describes as somewhat beneficial. Recent stressors include bullying incidents at school and his parents' ongoing divorce proceedings. He denies any hallucinations or delusional thinking.
Past Medical History (PMH):
Medical History: No significant medical history Psychiatric History: PTSD, Major Depressive Disorder (MDD)
Medications: Sertraline 50 mg daily
Allergies/Intolerance: No known drug allergies (N.K.D.A.)
Family History: Paternal history of depression Older brother with ADHD
Social History: Currently lives with mother and younger sister High school student, struggles with attendance due to anxiety No history of tobacco, alcohol, or drug use
Assessment: Patient is alert and oriented to person, place, and time. He appears well-groomed and cooperative during the session. His mood is described as "depressed," with a congruent affect. He exhibits no current evidence of hallucinations, suicidal ideation, homicidal ideation, or delusional thoughts.
Treatment/Plan: Medications: Continue Sertraline 50 mg daily.
Monitoring: Closely monitor depressive symptoms and potential side effects of medication. Psychotherapy Services: Maintain ongoing weekly sessions of cognitive behavioral therapy (CBT) to assist with PTSD and depression management.
Consider trauma-focused therapy as an adjunct. Lifestyle Recommendations: Encouraged regular physical activity to improve mood and sleep. Promoted consistent sleep hygiene practices to address sleep disturbances. Suggested participation in a peer support group at school to improve social interaction and reduce stress related to bullying.
Follow-up appointment in 4 weeks to assess treatment efficacy, monitor side effects, and evaluate the need for potential medication adjustment. Discussed potential introduction of Prazosin if nightmares persist by next visit. Need Assignment Help?