I need a psychiatric progress note regarding a patient with PPH: of Depression, Anxiety and Insomnia . It cannot be similar, Thank you.
Here below I leave you a sample.
Patient is a XXXX y/o, female with Past Psychiatric History of Depression, Anxiety and Insomnia was seen today on telehealth platform for follow up and medication treatment who alleges getting better with the last treatment of trazodone 50mg at bedtime and mirtazapine 7.5mg at bedtime, she reports decrease symptoms of sadness ,loneliness, depression , hopelessness, as well as she expresses feeling motivated, optimistic and with more energy in the morning, improve mood, self-esteem and affect because she feels useful ,decreased anxiety and stressing over her personal problems, restlessness, nervousness, as result decreased difficulty falling asleep because sleeping better and more hours at night with her previous treatment the melatonin 5mg at bedtime, also in the morning she waking up rested after a night’s sleep. Patient denies side effects of the medications, suicidal and homicidal ideation, no visual or auditory hallucinations, agitation, psychotic symptoms or paranoia .Follow up in 4 weeks.
ANSWER
[Your Name]
[Your Title]
[Date]
**Patient Name:** [Patient’s Name]
**Age:** [Patient’s Age]
**Gender:** Female
**Date of Appointment:** [Date of Appointment]
**Appointment Type:** Telehealth
**Chief Complaint:**
The patient presents with a history of depression, anxiety, and insomnia. She is here for a follow-up and medication evaluation.
**History:**
The patient is a XXXX-year-old female with a past psychiatric history of depression, anxiety, and insomnia. She has been receiving treatment and has recently been prescribed trazodone 50mg at bedtime and mirtazapine 7.5mg at bedtime.
**Presenting Symptoms:**
During today’s telehealth session, the patient reported a significant improvement in her overall well-being since starting the prescribed medications. She noted a decrease in symptoms of sadness, loneliness, depression, and hopelessness. The patient expressed feeling more motivated, optimistic, and energetic in the mornings. She reported an improved mood, increased self-esteem, and a more positive affect due to an enhanced sense of usefulness. Additionally, the patient described a reduction in her anxiety levels, including decreased worrying about personal problems, restlessness, and nervousness.
One notable improvement was in her sleep pattern. The patient reported that she was experiencing less difficulty falling asleep and was now enjoying better-quality sleep, with increased hours of rest at night. She credited her previous treatment of melatonin 5mg at bedtime for this improvement. She mentioned that she now wakes up feeling rested after a full night’s sleep.
**Medication Review:**
The patient denied experiencing any adverse side effects from the prescribed medications, including trazodone and mirtazapine.
**Risk Assessment:**
During the assessment, the patient denied any suicidal or homicidal ideation. She also reported no visual or auditory hallucinations, agitation, psychotic symptoms, or paranoia.
**Treatment Plan:**
The patient’s current treatment plan includes continuing with the prescribed medications, trazodone 50mg at bedtime and mirtazapine 7.5mg at bedtime. She will continue taking melatonin 5mg at bedtime for improved sleep.
**Follow-Up:**
The patient will be scheduled for a follow-up appointment in 4 weeks to assess her progress and make any necessary adjustments to her treatment plan.
**Summary:**
The patient has shown significant improvement in her mood, anxiety levels, and sleep patterns since initiating the prescribed medications. She reports feeling more motivated, optimistic, and energetic during the day, and her overall sense of well-being has improved. The patient will continue with her current treatment plan, and her progress will be monitored closely during the follow-up appointment.
[Your Name]
[Your Title]
[Medical Facility Name]
psychiatric progress note regarding a patient with PPH: of Depression, Anxiety and Insomnia
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