Progress Notes

Harbourside Psychology Clinic Level 4, 150 Pitt Street Sydney NSW 2000 (02) 9555 0143 (02) 9555 0144

Practitioner: Dr Sarah Jenkins, Clinical Psychologist

Surname: Vance First Name: Thomas Date of Birth: 14/05/1978

Progress Note

12 November 2024

Thomas is a 46-year-old divorced male who currently lives alone in a rented apartment in Marrickville.

He has a longstanding history of Bipolar I Disorder and hypertension. His mental health has remained largely stable over the past two years with adherence to lithium carbonate (Quilonum®) 900 mg PO nocte, alongside regular cognitive behavioural therapy (CBT) sessions.

Thomas attended today's session accompanied by his older sister, Claire. He was neatly groomed, dressed appropriately for the weather, and maintained good eye contact with a cooperative and pleasant demeanour throughout the review.

He reported that his mood has been stable and euthymic over the past month. He explicitly denied any feelings of worthlessness or hopelessness, and denied any suicidal or homicidal ideation. He stated that he feels safe and secure in his current home environment and denied experiencing any paranoia, delusions, or auditory and visual hallucinations.

Thomas maintains a strong, supportive relationship with his sister and attends a local community men's shed twice a week. He is currently managing his daily household chores, grocery shopping, and finances independently, though Claire assists him with transport to medical appointments when required.

He reported experiencing mild bilateral knee osteoarthritic pain over the last fortnight, particularly in the mornings. He was advised to engage in low-impact exercises such as swimming, and confirmed that his regular general practitioner (GP) is currently overseeing his pain management and monitoring his blood pressure.

1. Continue current prescribed pharmacotherapy, specifically lithium carbonate 900 mg PO nocte, as managed by his psychiatrist and GP.
2. Maintain attendance at the local community men's shed twice weekly to support ongoing social engagement.
3. Implement daily mood tracking and sleep hygiene strategies as discussed in session.
4. Return for a follow-up psychology appointment in 4 weeks to monitor ongoing mental health stability.

Thomas was advised to contact his GP or local mental health triage line immediately if he notices any early warning signs of relapse, such as decreased need for sleep or racing thoughts, prior to our next scheduled session.

Dr Sarah Jenkins, MPsych(Clin), PhD Clinical Psychologist