Tonalidad: C minor
Verse 1
Appointment and
Current
Presentation
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It was my pleasure to re view
Mark for the first time in the
Outpatient
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Clinic today, 1st of
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February, 2019.
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He came accompanied by his wife
Claire.
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He told me he feels much better an d stable
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in his mental state in recent weeks.
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He reported improvement in his mood and general feelings,
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feeling overall more positive and active.
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He said has found his sleep patterns very
much improved and never been so good.
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He did not report major impairment
in eating pattern and reward.
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He told me he is currently func
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tional and was back full time again.
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He reported residual anxiety,
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reaching panic peaks particularly reactively to stress or
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bad news during the day.
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He told me in these occasions he phoned his wife and
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responded well to reassurances and
encouragements.
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A mental state examination mark was appropriate in appearance,
we established a good rapport,
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he was pleasant,
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open and collaborative in the interview.
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His cognition was not formally tested but I could
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not identify and gross abnormalities.
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His speech was normal along with his thought process
I am content his mood has improved
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in recent weeks, his affect in clinic was euphemic,
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reactive and well modulated.
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There was no presence
of psychotic elements.
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He reported his
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PTSD as manageable recently,
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with anxiety and stress level as the prominent
problems.
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He did not express any thought,
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intention or plan to harm himself or others.
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He appeared sincerely regretful for the overdose and
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stress created to his family by his crisis.
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He appeared to have fair insight on his symptoms
and capacity regarding treatment choices.
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Mark tells us that he wants to just feel
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better and be functional again.
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We discussed his medication.
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Mark told me that after the overdose he stopped mirtazapine
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D
15 mg at night since he was perceiving it as too sedative.
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He also told me he reduced citrulline to 50
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mg in the morning since he had diarrhea.
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We discussed he has been taking sertraline for
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a long time and there are some queries
about if diarrhea was related to sertraline.
On the other hand, it appears he is doing well
in his mental state and we discussed
rationale and profile of sertraline
for the indications of
PTSD, anxiety and depression.
He also told me that around
December his compliance was rather poor.
He formally agreed that he will improve.
We discussed his diagnoses above,
as per his records,
Mark agreed with them.
We discussed psychoeducation around
anxiety and crisis management.
We discussed his risk contingency plan.
Mark told me he is able to seek help,
calling his wife or other people,
and he is also able to call his
GP and the mental health
services in case of need.
He told me that currently he does not feel at risk
and does not feel he needs a lot of
input from our service.
He finds psychological therapy as
beneficial and he is willing to continue.
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