Create another psych note scenario with another medication plan

Chief Complaint: Medication monitoring and management

History of Present Illness (HPI): The patient is a 45-year-old female presenting for telehealth consultation regarding medication management. She has a medical history marked by significant depression and anxiety. Recently, she underwent gallbladder surgery, which was uncomplicated but heightened her anxiety levels. The patient reports difficulty in managing her stress, leading to occasional insomnia. However, she maintains a good appetite, and her weight has remained stable. She experiences palpitations occasionally, which she attributes to anxiety.

Past Medical History (PMH): Medical History: Gallbladder Surgery Psychiatric History: Depression, Anxiety

Medications:

• Lexapro (Escitalopram) 10 mg PO daily
• Ativan (Lorazepam) 0.5 mg as needed for anxiety

Allergies/Intolerance: No known allergies (N.K.A.)

Family History: Mother had depression; no reported psychiatric issues in siblings or father.

Social History: Married and lives with her husband. Has three children: one son and two daughters. Employment: Works part-time as a graphic designer. No history of tobacco, alcohol, or substance use.

Assessment: The patient is alert and oriented to person, place, and time. She appears neatly dressed and expresses cooperation and insight into her condition. Denies experiencing any hallucinations or suicidal/homicidal ideations. Anxiety levels are slightly elevated but appear manageable with her current coping strategies.

Treatment/Plan:

• Continue the current medication regimen with Lexapro 10 mg daily.
• Prescribe Lorazepam 0.5 mg sparingly, advising use only when anxiety is severe and not manageable by other means.
• Recommend engaging in cognitive-behavioral therapy (CBT) sessions to develop better coping mechanisms for anxiety and stress management.
• Health check-up with regards to occasional palpitations to rule out any underlying cardiac issues.
• Schedule a follow-up appointment in 4 weeks to reassess medication efficacy and adjust treatment as needed.