And as contrast, the same person from berries.icu below. This requires a fair amount of editing to be useful and I do not like a lot of the structure. This one is just ridiculously bloated at the moment, more so than most exemplars even from berries. They are extremely responsive to feedback, however, and just in the past few days I've been toying with it they introduced a distinction between psychiatry f/u notes and therapy f/u notes, so we'll see if it gets better. They say customizable templates are coming soon - if it actually happens and it does allow real ability to specify structure it is closer to being usable.
I'm still struck a bit by the things the AI managed to interpolate from the conversation in terms of propositional attitudes and emotional state of the patient which I think were largely accurate but not discussed explicitly.
Subjective:
Chief Complaint: The patient reports stressors related to changes in employment and preparations for an impending wedding, but notes an overall good handling of these issues.
History of Present Illness (HPI): The patient begins the session acknowledging a lack of awareness about the scheduled appointment, indicative of a preoccupied state of mind linked to a new job started “last week” and an upcoming wedding "a month from yesterday". The patient expresses excitement about the marital event juxtaposed with the stress of commencing new employment at [REDACTED] to ensure income continuity. Describing the role as administrative, entailing tasks like checking in patients and verifying insurance, the patient is still in the process of being trained and evaluating the new work environment.
When probed about the choice of the current job, the patient conveyed an absence of deliberation, accepting the first offer received from a batch of applications to unspecified positions. A notable lack of confidence pervades the patient's discourse about future career aspirations. Contrastingly, the patient is handling a multitude of stressors including a demanding commute , moving residences, and wedding preparations unexpectedly well, remarking on a sense of personal growth and a feeling of being "unstuck."
The patient’s mood is described as "really good," and surprisingly uncomplicated considering the multitude of substantial life transitions. The patient acknowledges occasional negative feelings, mostly surrounding family and emotional complexities tied to wedding preparations but remains highly functional and positive. Sleep issues reported include difficulty falling asleep and waking up around "2 in the morning," characterized by staying awake for "like, 3 hours" before managing to sleep again. These disturbances occur approximately "once every 10 days" and have been more frequent in the past 6 months.
The patient notes a history of alcohol consumption negatively affecting sleep and is reducing intake with potential pregnancy in mind. The patient's adherence to current medication, 300 milligrams of extended-release Wellbutrin and 20 milligrams of Lexapro, is solid, with no reported side effects. Despite recent disruptions to therapy schedules due to the new job, the patient values the continuity in mental health treatment.
Symptoms Recap - Interval Changes:
1. Stress: The patient is experiencing notable life stressors related to job changes, wedding planning, and relocation but reports handling the stress "eerily well," which is a positive change.
2. Sleep disturbances: The patient describes new challenges with sleep, waking up in the middle of the night and staying awake for extended periods, with a frequency increase over the last six months.
Current Psychiatric Medications: The patient is currently taking 300 milligrams of extended-release Wellbutrin and 20 milligrams of Lexapro, with no reported issues concerning these medications.
Medication Adherence: The patient confirms ongoing adherence to prescribed psychiatric medications, with no reported missed doses.
Side Effects: The patient does not report any side effects from medication.
Sleep: The patient reports intermittent difficulty with sleep initiation and maintenance, which seems aggravated by alcohol consumption but is a recent and notable change.
Mood: The patient's mood is characterized as positive, with occasional stress responses, but generally resilient and buoyant.
Nutrition: No specific details on nutrition habits or consumption patterns are provided in the transcription.
Substance Use History:
- Alcohol: The patient consumes a reduced amount of "3 or 4 drinks a week" from an earlier level, mindful of potential pregnancy.
No other substance use or "process addictions" are mentioned.
Past Psychiatric History: The patient is currently engaged in weekly therapy sessions, although recent employment changes have disrupted this schedule.
Social History: The patient is soon to be married, is currently engaged in fixing up a property for living post-wedding, and is actively managing properties with an intent to rent for income and retain equity.
Objective:
- General Appearance and Behavior: The patient's attire and grooming were appropriate, with no significant peculiar behaviors observed during the visit.
- Motor Activity: The patient displayed normal motor activity, with no indications of abnormal movements or restlessness noted.
- Speech: The patient exhibited coherent speech with appropriate volume and speed, showing no signs of language impairments.
- Eye Contact: The patient maintained regular eye contact during the visit, with no indications of unusual patterns.
- Affect: The patient's affect was predominantly positive, displaying a wide range of appropriate emotional expressions in response to various topics discussed.
- Thought Process: The patient's thought process reflected organized and coherent thinking, with logical discussion and no indications of disorganized thinking.
- Cognition: The patient demonstrated intact cognitive function, displaying orientation and clear memory throughout the conversation.
- Insight & Judgment: The patient expressed insight into personal challenges and demonstrated sound judgment while discussing life decisions.
- SI (Suicidal Ideation): The patient did not report any suicidal ideation during the visit.
- HI (Homicidal Ideation): The patient did not express any homicidal thoughts or ideations.
- AH (Auditory Hallucinations): No reports or signs of auditory hallucinations were observed during the visit.
- VH (Visual Hallucinations): The patient did not mention any visual hallucinations during the visit.
Assessment & Plan:
Assessment:
The patient reports life changes including a new job, an upcoming wedding, the patient's move, and the future husband's house renovations. While these events are stressors, the patient expresses handling these changes surprisingly well, reflecting a potential adjustment disorder with mixed anxiety and depressed mood symptoms. Despite some sleep disturbances, like waking up in the middle of the night, the patient's mood remains generally positive, with moments of stress related to wedding planning and concern for a sick pet. The sleep issues hint at insomnia due to another mental disorder, potentially exacerbated by alcohol consumption. Medication adherence to Wellbutrin and Lexapro is consistent, and no side effects are reported; however, therapy sessions have not been maintained regularly due to the patient's current workload. There is no indication of thoughts of self-harm or risk to others.
Plan:
- Continue current medications (Wellbutrin 300mg ER and Lexapro 20mg) barring any new side effects or concerns.
- Encourage the patient to continue engagement with psychological therapy as it can be beneficial during times of significant life changes, once a more suitable schedule is identified.
- Advise the patient to monitor alcohol intake, particularly as it pertains to sleep quality, and consider abstaining to evaluate its impact on sleep.
- Educate about proper sleep hygiene practices to address insomnia and establish a regular sleep schedule, especially in light of variable work hours.
Follow-Up:
- Schedule the next appointment for 8 weeks, with flexibility based on the patient's insurance changes and financial considerations. Encourage the patient to reach out if they need to reschedule or opt for an alternative plan.
