Mental Health Record
Patient Information
Field | Details |
|---|
Patient Name: | Antonette Cassin |
Age: | 65 |
Gender: | Female |
Address: | Moreno Valley, CA 92551 |
Phone Number: | 222 555 7777 |
Emergency Contact: | Ben Cassin |
Relationship: | Husband |
Primary Care Physician: | Dr. Sarah Green |
Referring Physician: | Dr. Michael White |
Presenting Problem
Date of Consultation: March 4, 2095
Reason for Visit: Patient reports feelings of depression and memory loss.
Symptoms Reported: Persistent sadness, difficulty concentrating, forgetfulness.
Duration of Symptoms: Symptoms present for the past 6 months.
Mental Health History
Past Diagnoses: Depression, Anxiety Disorder (diagnosed in 2050)
Previous Treatments: Cognitive Behavioral Therapy (CBT) 2050-2055, Antidepressant Medication (Fluoxetine)
Medications: Currently on antidepressant (Sertraline, 50mg daily).
Hospitalizations: Hospitalized for depression in 2052.
Therapy/ Counseling History: Attended therapy intermittently from 2050-2055.
Mental Health Assessment
Area | Observations and Notes |
|---|
Mood | Low mood, reports feeling sad most days. |
Affect | Blunted affect, limited emotional expression. |
Thought Content | No evidence of delusions or hallucinations, but reports constant worry. |
Perception | No perceptual disturbances noted. |
Cognition | Mild cognitive impairment, difficulty with short-term memory. |
Memory | Impaired recall of recent events. |
Judgment/Insight | Fair judgment, insight into condition is somewhat limited. |
Risk Assessment | No current risk of self-harm or harm to others. |
Diagnosis
Treatment Plan
Goals: Improve mood, reduce depressive symptoms, enhance cognitive functioning.
Interventions: Weekly cognitive-behavioral therapy (CBT) sessions, continue Sertraline, consider neuropsychological testing.
Medications Prescribed: Increase Sertraline dosage to 100mg daily.
Referrals: Referred to Neurologist for further cognitive assessment.
Follow-up Plan: Follow-up appointment in 2 weeks for medication review and therapy update.
Notes and Recommendations
Encourage patient to engage in regular physical activity to support mental health. Recommend social support groups for elderly individuals with cognitive concerns.
Provider Information
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