Psychiatry Progress Note

Psychiatry Progress Note:
The patient presents with complaints of significant anxiety and recurrent flashbacks that have progressively worsened since experiencing a traumatic workplace accident approximately six months ago. The patient describes being pinned under equipment during the incident, which was terrifying, though not resulting in serious physical injury. Since the event, the patient reports experiencing flashbacks several times per week, often accompanied by difficulty breathing and impaired concentration. The patient remains persistently on edge, is easily startled by loud noises, and has difficulty initiating and maintaining sleep nearly every night. The patient describes feeling emotionally numb, fatigued, and less socially engaged, stating, "I don’t go out as much." There is a notable reduction in participation in previously enjoyed activities. The patient denies any prior similar episodes before the accident. The symptoms have had a substantial negative impact on daily functioning, including social withdrawal and decreased occupational engagement.

MENTAL STATUS EXAMINATION:
The patient appears fatigued and describes feeling emotionally numb and jumpy. There is no mention of sadness or hopelessness. The patient's affect is restricted, and the emotional response is congruent with the described traumatic experience. Thought process is logical and goal-directed, with no evidence of delusions or disorganized thinking. The patient reports intrusive flashbacks but does not describe hallucinations or other perceptual disturbances. Insight into the condition is present, as the patient recognizes the connection between symptoms and the traumatic event. Judgment appears intact, as the patient seeks help and is receptive to treatment recommendations. Memory, orientation, concentration, and comprehension are grossly intact; however, not formally assessed.

PHYSICAL EXAMINATION:
A physical examination was conducted. The patient reports that they were not seriously hurt during the workplace accident.

IMPRESSION:
The clinical presentation is consistent with post-traumatic stress disorder, characterized by persistent anxiety, recurrent intrusive flashbacks, hyperarousal, sleep disturbance, emotional numbing, and social withdrawal following a traumatic workplace accident. No alternative differential diagnosis is provided.

PLAN:
Treatment planned: Initiate sertraline at 25 mg daily, with gradual titration as tolerated. No immediate medication for acute anxiety prescribed. Relevant other actions: Referral to a therapist specializing in trauma-focused therapy. Next appointment date for psychiatric follow-up: Plan to review in approximately four weeks or sooner if symptoms worsen.