S: C.L is a 26-year-old male who reports he has had a relapse of a constantly low depressed mood for the last month. He reports a significant appetite increase and has gained over 15 pounds. Additionally, he reports feeling fatigued most of the day and sleeps more than 12 hours. He also says he is experiencing anhedonia, feels worthless and is unable to go to work.
O: Patient is alert, oriented, and well-groomed. He has a depressed mood, coherent thought, good judgment and insight. There are no hallucinations or delusions.
A: The patient has a relapse of depressive episodes and is concerned about how the symptoms are impacting his life.
P: Zoloft 50 mg oral OD.
S: A.D is a 27-year-old female with marked distress after losing her job. She reported having a hard time adjusting to life after job loss and considers the loss a major failure in her life. She reported that in the past four months she has been having excessive worry, anxiety, sleeping difficulties, and is constantly angry. She mentioned that although she got a new job two months later, she feels trapped and isolated and does not like the job. As a result, she has poor concentration levels and has not been performing compared to her previous job.
O: The self-reported mood was anxious and affect appropriate. She demonstrates a coherent thought process. She has a good judgment and abstract reasoning.
A: Problems with adjustment.
P: Paroxetine 20mg orally once daily.
S: F.L is a 15-year-old female who presented with complaints of having intrusive thoughts about a fatal road accident she was involved in seven months ago, which left her with a broken femur. She witnessed several people profusely bleeding and two died on the spot. The memories of the accident constantly recollect in her mind, which give her an intense fear and leave her helpless. She reported having flashbacks about the accident. Consequently, she avoids travelling because being in a car reminds her of the traumatic event. She stated that she often gets distressed when in a vehicle, which is accompanied by palpitations and profuse sweating. The client also reported having difficulties sleeping because she often gets nightmares about the accident.
O: Anxious and fidgets a lot. Coherent speech and thought process.
A: Startled reaction and avoidance.
P: Paroxetine 30mg orally once daily.
S: D.C is a 24-year-old female with an obsession of doubt characterized by constantly checking doors and locks in her house and shop. She reported having an abnormal concern about having forgotten to lock the door upon leaving the house and her shop. The doubt causes marked psychological distress, which compels her to frequently check the locks. She reports that she has in many occasions left her house at night to go check if she locked her shop. Besides, she frequently wakes up at night with doubts of having failed to lock the door. The obsession of doubt has contributed to poor concentration levels while at work since she is always concerned that she did not lock the house door.
O: Anxious and fidgets a lot. Coherent speech and thought process.
A: The obsessions and compulsions are time-consuming and interfere extensively with her normal routine.
P: Clomipramine 25 mg PO qDay.
S: W.S is a 16-year-old female who presented with a depressed mood for about six weeks, characterized by feeling sad, empty, and hopeless most of the day and nearly every day. She also reported having a decreased appetite which had caused a weight loss of about 12q pounds. She had low energy levels and would feel fatigued even after sleeping for long hours. She reported having lost interest in most pleasurable activities and decreased ability to concentrate and make decisions.
O: The self-reported mood is sad, and affect is broad. Her speech is clear with normal volume and rate. The thought process is coherent. No delusions, hallucinations, or suicidal/homicidal ideations were noted.
A: PHQ-16. Impaired school and social functioning.
P: Zoloft 50 mg oral OD.
S: S.D is a 13-year-old female with recurrent and persistent thoughts about being dirty and contracting disease-causing organisms. The obsession with thoughts and ideas that she might have contracted microbes led to marked anxiety
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