Question: Write a follow up psychiatric note, chief complaint, current Meds, HPI, formulation, recommendation treatment plan for a 51 years old male with diagnosis of Alcohol use disorder, Severe, In early remission, Posttraumatic Stress Disorder and Major depressive disorder, Recurrent episode, With psychotic features Chief Compliant: Follow up psychiatric visit and medication refills Current Meds: buPROPion HCl XL 300 mg 24 hr tablet, extended release, prazosin 2 mg capsule for nightmares, OLANZapine 5 mg tablet at HS HPI: He said he has been doing well. she said lately she has been exploring his childhood trauma with his therapist and also attending substance abuse classes. He said he did use illicit drugs a lot when he was very young and his therapist is exploring all of that. He said he sometimes wake up every hour or two at night (the last two week) and he feels it is because he is talking about his childhood trauma with his therapist. He said he still have nightmares somedays but he is able to fall back asleep. He said he still gets at least 7hours of sleep at night. He loves listening to music and loves watching movies on Netflix. He said he is not able to go the gym because he has to be approved by his CCO (community Corrections officer). He said his CCO has also asked him to keep records of every job application he is applying for.
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