Psychiatric Progress Note For Patient With Depression 956910

Question

Psychiatric Progress Note for Patient with Depression, Anxiety, and Insomnia Patient is a 45-year-old female with a history of depression, anxiety, and insomnia who was seen today via telehealth for follow-up and medication management. The patient reports significant improvement in her symptoms since the last visit, particularly noting decreased feelings of sadness, hopelessness, and loneliness. She reports feeling more motivated, optimistic, and energized during the mornings, which has positively affected her overall mood and self-esteem. The patient describes her affect as more stable and responsive, attributing her improvements to adherence to her current medication regimen. Currently, the patient is taking trazodone 50 mg at bedtime and mirtazapine 7.5 mg at bedtime. She reports that these medications have contributed to her sleep quality, with decreased difficulty falling asleep and more restful sleep lasting throughout the night. She notes waking up feeling refreshed and rested most mornings. The patient also reports decreased anxiety levels and reduced stress related to personal concerns, which has contributed to her ability to relax and maintain a more balanced daily routine. The patient denies experiencing any adverse side effects from her medications, such as sedation, weight gain, or gastrointestinal issues. She also denies any current thoughts of suicidality or homicidality, as well as hallucinations, paranoid thoughts, agitation, or psychotic symptoms. No signs of emotional instability or behavioral disturbances were observed during the session. In addition to pharmacological management, the patient reports engaging in regular physical activity and practicing relaxation techniques such as mindfulness, which she finds helpful in managing her anxiety and improving her sleep hygiene. She expresses motivation to continue with her current treatment plan and is interested in exploring additional supportive therapies if needed in the future. Plan includes cont

Dr. Jack HW Helper · Accepted Answer

Psychiatric Progress Note for Patient with Depression, Anxiety, and Insomnia Patient is a 45-year-old female with a history of depression, anxiety, and insomnia who was seen today via telehealth for follow-up and medication management. The patient reports significant improvement in her symptoms since the last visit, particularly noting decreased feelings of sadness, hopelessness, and loneliness. She reports feeling more motivated, optimistic, and energized during the mornings, which has positively affected her overall mood and self-esteem. The patient describes her affect as more stable and responsive, attributing her improvements to adherence to her current medication regimen. Currently, the patient is taking trazodone 50 mg at bedtime and mirtazapine 7.5 mg at bedtime. She reports that these medications have contributed to her sleep quality, with decreased difficulty falling asleep and more restful sleep lasting throughout the night. She notes waking up feeling refreshed and rested most mornings. The patient also reports decreased anxiety levels and reduced stress related to personal concerns, which has contributed to her ability to relax and maintain a more balanced daily routine. The patient denies experiencing any adverse side effects from her medications, such as sedation, weight gain, or gastrointestinal issues. She also denies any current thoughts of suicidality or homicidality, as well as hallucinations, paranoid thoughts, agitation, or psychotic symptoms. No signs of emotional instability or behavioral disturbances were observed during the session. In addition to pharmacological management, the patient reports engaging in regular physical activity and practicing relaxation techniques such as mindfulness, which she finds helpful in managing her anxiety and improving her sleep hygiene. She expresses motivation to continue with her current treatment plan and is interested in exploring additional supportive therapies if needed in the future. Plan includes cont

Psychiatric Progress Note for Patient with Depression, Anxiety, and Insomnia

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