Psychiatric Hospital Note

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Patient Name: Jeremy Marvin
Date: October 8, 2050
Time: 10:00 AM
MRN: 123456
Clinician: Dr. [Your Name], MD
Facility: [Your Company Name]

Subjective:

Chief Complaint: “I’ve been feeling very anxious and unable to sleep.”

History of Present Illness: The patient is a 28-year-old male who reports increased anxiety over the past two weeks, triggered by work-related stress. He describes feelings of restlessness, difficulty concentrating, and frequent worries about his job performance. The patient reports difficulty falling asleep and waking up several times during the night. He denies any suicidal ideation or intent.

Past Psychiatric History:

• Diagnosed with Generalized Anxiety Disorder (GAD) three years ago.

• Previous treatment with SSRIs; currently not taking any medication.

• No history of psychiatric hospitalizations.

Social History:

• Lives alone in an apartment.

• Employed full-time as a software engineer.

• No substance use was reported.

Objective:

Mental Status Examination:

• Appearance: Well-groomed

• Behavior: Cooperative

• Mood: Anxious

• Affect: Congruent

• Thought Process: Logical and coherent

• Thought Content: No delusions or hallucinations

• Insight: Fair

• Judgment: Fair

Assessment:

• Generalized Anxiety Disorder, currently exacerbated by situational stressors.

• Sleep disturbance secondary to anxiety.

Plan:

1. Medication: Initiate treatment with Sertraline 50 mg daily.

2. Therapy: Refer to cognitive behavioral therapy (CBT) to address anxiety management techniques.

3. Sleep Hygiene: Educate on sleep hygiene practices.

4. Follow-up: Schedule a follow-up appointment in one month to assess response to medication and therapy.

Signature:

Dr. [Your Name], MD
[Your Company Name]

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