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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