Depression Assessment

Subjective:
Chief Complaint:
Recurrent nightmares and increased daytime anxiety, ongoing for an unspecified duration.

History of Present Illness:
Julia reports persistent nightmares occurring almost nightly, resulting in significant sleep disturbance and daytime exhaustion. She describes increased anxiety during the day, decreased motivation, and feeling overwhelmed by routine tasks. The nightmares have remained consistent in content but are causing cumulative distress and functional impairment.

Past Psychiatric History:
No past psychiatric diagnoses, hospitalizations, or suicide attempts were discussed.

Family History:
No family psychiatric history was provided.

Social History:
No information regarding occupation, living situation, substance use, or support system was provided.

Objective:
Medications:
Julia is currently prescribed sertraline at a dose of 100 milligrams. No other current or past psychiatric medications were mentioned. She reports ongoing symptoms despite this regimen.

Mental Status Examination:
Julia appears fatigued and reports feeling exhausted. Her affect is described as anxious and demotivated. No abnormalities in speech, thought process, cognition, insight, or judgment were described.

Assessment:
Risk Assessment:
No suicidal ideation, homicidal ideation, or self-harm behaviors were reported or assessed.

Diagnosis:
Major depressive disorder, recurrent, moderate (F33.1). F33.1

Plan:
Treatment Plan:
Initiate prazosin at a low dose to target trauma-related nightmares and sleep disturbance. Continue sertraline at 100 milligrams. Monitor response to medication changes. Schedule follow-up in two weeks, with instructions to contact the clinic earlier if adverse effects such as dizziness or worsening nightmares occur.

Patient Education:
Julia was informed about the use of prazosin for trauma-related nightmares and its potential to improve sleep, which may help reduce daytime anxiety. The possibility of considering bupropion in the future for persistent low motivation and energy was discussed. Julia was advised to monitor for side effects and to reach out if symptoms worsen.

Disclaimer:
Billing codes are only intended as a guide. It is the healthcare provider's responsibility to ensure their appropriateness and accuracy for each consultation.