2715/2712

"Patient consented to AI scribe and Mental Health Care Plan" "Aware of schedule of fees" History of Presenting Complaint (HOPC): * Mood: Low mood for the past 6 months. * Anhedonia: Loss of interest in activities. * Sleep: Difficulty sleeping, waking up early. * Thoughts of guilt or worthlessness. * Energy levels: Low energy levels. * Suicidal thoughts: Occasional thoughts of suicide, no attempts. The patient's symptoms have gradually worsened over the past six months. The low mood and anhedonia are persistent, and the sleep difficulties have become more frequent. The patient reports that the suicidal thoughts are fleeting but concerning. The patient is experiencing significant stress due to financial difficulties and relationship problems. Alcohol and Other Drugs (AOD): * Drinks alcohol occasionally, about once a week. * Smokes 10 cigarettes a day. * No illicit drug use. Psychiatric History: * Major Depressive Disorder * Anxiety Disorder Medication and Allergies: * No known allergies. * Sertraline 50mg daily. Social History: * Renting a flat, lives alone. * Single. * Employed as a teacher. Family History: * Mother has a history of depression. Impression: Patient presents with symptoms consistent with Major Depressive Disorder and co-morbid Anxiety Disorder. Risk stratification is low to moderate, with suicidal ideation present but no active plans or attempts. Further assessment and intervention are required. Plan: * Continue Sertraline 50mg daily. * Referral to a psychologist for Cognitive Behavioral Therapy (CBT). * Encourage regular exercise and a healthy diet. * Discussed the importance of social support and connecting with friends and family. "Safety planning 1. Self-soothing (distraction techniques, breathing exercises, mindfulness or exercise) 2. Phone a friend (family, friends or partner) 3. Organisations (Lifeline 13 11 14, Samaritans 0863 839 850, MHERL 1300 555 788) 4. Go to ED"