Question: Create another psych scenario note for a 45 year old female with medical history using this format Chief Complaint: Medication monitoring and management History of

Create another psych scenario note for a 45 year old female with medical history using this format

Chief Complaint: Medication monitoring and management

History of Present Illness (HPI):

The patient is a 56-year-old female with a history of depression and multiple medical issues, including a recent hernia repair that led to a myocardial infarction (MI) and a code event while hospitalized.

She presents today via telehealth for medication management. The patient reports sleeping well and eating adequately via a G-tube. She mentions experiencing a slight increase in anxiety.

Past Medical History (PMH):

Medical History: Hernia Repair, MI

Psychiatric History: Depression, Anxiety

Medications:

Zoloft (Sertraline) 25 mg PO daily

Allergies/Intolerance:

No known allergies (N.K.A.)

Family History:

No reported psychiatric history

Social History:

Married and lives with husband

Has four children: two sons and two daughters

Employment: Works as a maintenance personnel

No history of alcohol or substance use

Assessment:

The patient is alert and oriented to person, place, and time.

Appears neatly dressed and cooperative.

Denies experiencing hallucinations or having suicidal or homicidal ideations (SI/SH).

Treatment/Plan:

Continue current medication regimen with Zoloft 25 mg daily.

Monitor mood and behaviors closely and report any changes to the psychiatry team.

Recommend follow-up with a psychologist for ongoing management and support.

Follow-up appointment in 4 weeks to reassess and adjust the treatment plan as necessary.

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