• Patient Name: Sarah Jenkins
• Date of Birth: 14/08/1988
• Date of Consultation: 12/05/2024
• Medical Record Number: 849-201-44

Mental Health Appointment Documentation

Reason for Visit

• Assessment and Management of Mental Health Concerns: Review of worsening anxiety and low mood; Mental Health Treatment Plan (MHTP) renewal.

Presenting Issue

• Symptoms: Persistent worry, initial insomnia, fatigue, poor concentration, and anhedonia.
• Duration: 6 weeks, triggered by workplace restructuring.
• Impact on Daily Life: Struggling to meet work deadlines; withdrawing from social activities.

Past Psychiatric History

• Previous Diagnoses: Generalised Anxiety Disorder (GAD), Major Depressive Disorder (MDD) in 2019.
• Previous Treatments: Cognitive Behavioural Therapy (CBT) in 2019 (10 sessions); sertraline 50 mg PO daily for 12 months (ceased 2020).
• Hospitalisations: Nil.

Current Medications

• Medication Name: Escitalopram (Lexapro®) 10 mg PO mane (commenced 4 weeks ago).
• Adherence: Good; takes daily as prescribed.
• Side Effects: Mild transient nausea in the first week, now resolved. No agitation or insomnia from medication.

Mental Status Examination

• Appearance: Well-groomed, casually dressed, appears stated age.
• Behaviour: Cooperative, mild psychomotor restlessness (fidgeting with hands), good eye contact.
• Speech: Normal rate, rhythm, and volume.
• Mood: "Stressed and exhausted."
• Affect: Anxious and restricted, congruent with mood.
• Thought Process: Linear, logical, and goal-directed.
• Thought Content: Preoccupied with work performance and job security. No delusions, hallucinations, or obsessions.
• Cognition: Alert and oriented to time, place, and person. Attention intact during consult.
• Insight: Good; recognises symptoms as a relapse of anxiety and depression.
• Judgment: Intact; proactively seeking medical and psychological support.

Assessment

• Diagnosis/Working Diagnosis: Relapse of Generalised Anxiety Disorder and Major Depressive Disorder.
• Severity: Moderate; K10 score 28/50. Causing moderate occupational and social impairment.

Treatment Plan

• Medications: Increase escitalopram (Lexapro®) to 20 mg PO mane.
• Therapy: Referral for focussed psychological strategies (CBT) under MHTP.
• Lifestyle Modifications: Sleep hygiene education, reduce caffeine intake to 1 cup prior to 12:00, daily 30-minute walk.
• Follow-Up: Review in 2 weeks to assess response and tolerability of dose increase.

Safety Assessment

• Suicide Risk: Low risk. Denies suicidal ideation, intent, or plan. Strong protective factors (supportive partner, future-oriented).
• Self-Harm Risk: Low risk. No history or current thoughts of deliberate self-harm.

Patient and Family Support

• Support Systems: Lives with supportive husband (David) and has close relationship with sister nearby.
• Emergency Contacts: David Jenkins (Husband) - 0412 345 678. Provided Lifeline (13 11 14) and Beyond Blue (1300 22 4636) details.

Next Steps

• Follow-Up Appointment: Booked for 26/05/2024 at 10:30.
• Referrals: Referred to Mr Mark Evans (Clinical Psychologist) under Better Access initiative (6 initial sessions).
• Additional Testing: FBE, UEC, LFT, TSH, Vit D, and ferritin ordered to exclude organic contributors to fatigue.

Signature

Dr Emily Chen

General Practitioner, FRACGP

Yarra Family Medical Centre, (03) 9555 1234

Date: 12/05/2024