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PROGRESS NOTE
Subjective:
Date and Time of Service:
Chief Complaint: Follow-up visit. "I am still experiencing anxiety and panic attacks."
History of Presenting Illness: J.D., a 43-year-old Caucasian male, presents for a follow-up visit
for medication management and mood stabilization. His medication includes Lithium Carbonate-
300 MG TAB, PO, Abilify- 10 MG TAB, and Benztropine 0.5mg- 1mg. He reports mild anxiety
related to his homelessness and feeling twitchy after consuming coffee. He denies feelings of
hopelessness, worthlessness, or helplessness at present. J.D. shares his dislike for Abilify and
requests to discontinue the medication, referring to a previous discussion with another doctor
who mentioned discontinuing Abilify when he starts Lithium. Laboratory findings show Mild
elevation for triglycerides 180 H <150 mg/dL UL, glucose 172 H 65-139 mg/dL, but lithium 0.4
L 0.6-1.2 mmol.
Behavior Described: cooperative, calm, compliant.
Past Psychiatric History: previous psychiatric hospitalization
Objective:
Mental Status Exam:
Mental Status Appearance: ☒ Clean ☒ Well-groomed ☐ Dirty ☐ Disheveled ☐
Inappropriate clothing
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Orientation: ☒Person ☒ Place ☒ Situation ☒ Time ☐ Disoriented
Speech: ☒ Organized/Clear ☒ Coherent ☒ Rapid ☐ Slowed ☐ Mumbling
Thought Process: ☒ Organized ☒ Coherent ☐ Tangential ☐ Thought Blocking ☐ Flight of
Ideas ☐ Poor Concentration ☐ Obsessive
Thought Content: ☒ Normal ☐ Delusional ☐ Grandiose ☐ Other
Perceptual Process: ☒ Normal ☐ Auditory hallucinations ☐ Visual hallucinations ☐ Other
Insight: ☒ Good ☐ Average ☐ Poor ☐ None
Judgment: ☒ Good ☐ Average ☐ Poor ☐ None
Mood: ☒ Normal ☐ Hopeless ☐ Irritable ☐ Elevated ☐ Labile ☐ Depressed ☐ Sad ☐
Anxious ☐ Manic ☐ Angry
Affect: ☒ Appropriate ☐ Inappropriate ☐ Blunted ☐ Flat ☐Tearful
Memory: ☒ Intact ☐ Immediate Memory Problem ☐ Recent Memory Problem ☐ Remote
Memory
Estimated Intellectual Functioning: ☒ Average ☐ Below Average
Cognitive Deficits: ☒ None ☐ Cognitive Deficits Present ☐ Concentration Deficits Present
Diagnosis:
ICD10: F25.0 - schizoaffective disorder, bipolar type
ICD10: F31.2 - Bipolar I disorder, current or most recent episode manic, with psychotic features.
ICD10: F12.20 - Cannabis use disorder, moderate
ICD10: F10.20 - Alcohol use disorder, moderate
Risk Assessment:
Suicide Risk: Low. J.D. denies suicidal ideation, intent, or plan during the session. He does not
exhibit any behaviors or indications of an imminent risk of self-harm.
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Homicide Risk: Low. J.D. denies homicidal ideation, intent, or plan. There are no reported
indicators of violent or aggressive behavior.
Violence and Dangerous Behavior Risk: Low. J.D. denies engaging in dangerous or violent
behaviors during the session. There are no reported incidents or indications of potential harm to
self or others.
Treatment Plan:
Continue Lithium Carbonate at the prescribed dosage of 300 mg orally, two
tablets at bedtime, as it helps stabilize mood and manage bipolar symptoms.
Continue Abilify at the prescribed dosage of 10 mg orally, one tablet at bedtime,
as it helps manage symptoms of schizoaffective disorder and bipolar disorder.
Increase Benztropine from 0.5 mg to 1 mg orally twice daily to target
extrapyramidal side effects (EPS) associated with antipsychotic medications. This
adjustment aims to alleviate the observed tremors in J.D.'s upper extremities.
Provide psychoeducation to J.D. regarding the potential benefits, risks, and side
effects of the prescribed medications and ensure J.D. understands the importance of
medication adherence and role the medications play in stabilizing his mood and
managing his psychiatric conditions.
The following recommendations are given:
Ensure J.D. is fully informed about the risks, benefits, and potential side effects of
the prescribed medications by educate him on the importance of medication adherence
and the role of the drugs on his condition.
Provide J.D. with clear instructions on what to do in emergencies, such as
worsening symptoms, severe side effects, or thoughts of harming himself or others.
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Advise him to contact 911, crisis team, or the nearest emergency room immediately in
such situations.
Encourage J.D. to maintain a healthy diet and engage in regular physical exercise
as balanced diet and regular exercise contribute to his overall well-being and potentially
improve his symptoms.
Emphasize the importance of continuing with psychotherapy. Psychotherapy
provides valuable support and help J.D. develop coping strategies, manage stress, and
address underlying psychological factors.
Urge J.D. to abstain from alcohol, cannabis, and illicit drugs. Substance use
interact negatively with psychiatric medications, interfere with treatment effectiveness,
and exacerbate symptoms.
Recommend that J.D. schedule a follow-up appointment with his primary care
provider to discuss the results of his lipid panels and glucose levels.
Schedule a follow-up visit in 2 days or sooner to assess J.D.'s progress, monitor
medication efficacy, address any concerns or side effects, and make any necessary
adjustments to the treatment plan.
