Problem:
Write a follow up psych progress note on this same patient creating a scenario to add to this previous visit note which result in the increase of her medication Zoloft to 100mg and prompting a follow up in 2 weeks Maintain this pattern.
Chief Complaint: follow up for Medication monitoring and management HPI: Patient is a 44-year-old male returning for follow-up after starting treatment with Zoloft (Sertraline) 50 mg daily 4 weeks ago for moderate depression. Patient reports mild improvement in mood and anxiety. He states that although his depression persists, he experiences intermittent periods of relief. His concentration and energy levels remain low, impacting his work performance and daily activities. Sleep has shown some improvement in terms of falling asleep, but he still experiences early morning awakenings. Patient acknowledges occasional urges to drink but has remained abstinent for over six months. Medication: Zoloft (Sertraline) 50 mg PO daily: Reports mild improvement in depressive symptoms with no adverse effects noted. Therapeutic Interventions: The patient participates in weekly outpatient therapy sessions focused on cognitive-behavioral techniques to address depressive symptoms and alcohol cravings. He acknowledges the benefits of therapy but sometimes struggles with implementation outside sessions. Social History Update: Patient lives with a supportive partner and two children. He has reduced his social engagements since his mood has worsened, feeling less motivated to engage with friends or family. However, he has maintained regular attendance at a local support group for individuals recovering from alcohol abuse. Mental Status Exam: Appearance: Neatly groomed, dressed appropriately for the season. Behavior: Cooperative and attentive, though maintains a slightly withdrawn demeanor. Speech: Normal rate and volume, though somewhat monotonic. Mood: Describes mood as "flat and anxious." Affect: Constricted but congruent with mood. Thought Process: Logical and goal-directed with no flight of ideas or loose associations. Thought Content: Occasional ruminations on personal adequacy and self-worth, but denies any suicidal ideation. Insight/Judgment: Fair, actively participating in treatment and express desire for improvement. Assessment: Diagnosis: Moderate Depression with mild improvement on the current medication regimen, history of Alcohol Use Disorder (in remission).
Plan: Medication: Increase Zoloft (Sertraline) from 50 mg to 75 mg PO daily to enhance therapeutic effect on depressive and anxiety symptoms. Monitor for side effects and efficacy. Therapeutic Interventions: Encouraged a continued participation in therapy sessions. Focus on integrating cognitive-behavioral strategies into daily routine, especially techniques designed to enhance mood and manage cravings. Lifestyle Recommendations: Discussed the importance of a balanced routine, including regular physical activity, sufficient sleep, and nutritional intake; recommend starting light exercise and relaxation techniques. Support Systems: Reinforced the importance of consistent engagement with support groups and maintaining communication with supportive network. Follow-up in 2 weeks to assess medication adjustment effectiveness and overall treatment progress. Need Assignment Help?