Natalie's Pediatric and Adolescent Psychiatry Note (custom) Template

ID:  
Emily Johnson, 14, she/her, 9th grade, Lincoln High School, student, resides in Manchester with her mother Sarah Johnson (nurse) and father Mark Johnson (engineer). Siblings: Jake (10) and Lily (8). Pets: Dog named Max.
Reason for referral:  
Referred to psychiatry due to escalating anxiety and depressive symptoms.
Chief Complaint:  
"I feel anxious all the time and can't focus on anything," Emily expressed. Her parents are worried about her withdrawal from social activities.
History of Presenting Illness:  
Emily has been experiencing increased anxiety over the past six months, especially concerning schoolwork and social interactions. She reports feeling overwhelmed and struggles to concentrate on tasks. Her parents have observed that she has become more withdrawn and irritable. Emily also reports experiencing low mood and a lack of interest in activities she previously enjoyed, such as playing soccer.
Psychiatric Review of Systems:  
Emily reports generalized anxiety symptoms, including restlessness, irritability, and difficulty concentrating. She experiences panic attacks approximately twice a week, lasting around 15 minutes, which are somewhat alleviated by listening to music. Emily denies any symptoms of obsessive-compulsive disorder, separation anxiety, PTSD, or psychosis. She reports depressive symptoms such as persistent sadness, fatigue, and changes in sleep patterns. No symptoms of bipolar disorder or eating disorders are present. Emily has difficulty with attention and focus, suggestive of ADHD. No behavioral difficulties such as oppositional defiant disorder or conduct disorder are reported.
Past psychiatric history:  
No past psychiatric diagnoses or hospitalizations. No past suicide attempts or self-harming behavior. Emily is currently seeing a school counselor for support. No past psychological testing.
Past medical history:  
Asthma, managed with inhalers.
Medications:  
None
Past Medications:  
None
Allergies:  
NKDA
Family History:  
Mother has a history of anxiety disorder.
Developmental history:  
Normal birth and delivery. Met developmental milestones on time.
Social History:  
Emily is a student in 9th grade. She enjoys reading and playing soccer. She has a close group of friends but has recently withdrawn from social activities. No alcohol or drug use. No legal activity. Not currently sexually active. Identifies as straight. No history of sexual or physical abuse.
Psychometric Assessments:  
None conducted.
Mental Status Examination:  
Emily is dressed appropriately for her age and maintains good hygiene. She appears anxious and fidgets during the interview. Her speech is clear and coherent, though she speaks softly. Emily describes her mood as "anxious and sad." Her affect is congruent with her stated mood. Thought processes are logical, with no evidence of delusions or hallucinations. She is oriented to time, place, and person, with intact memory and concentration. Emily demonstrates insight into her condition and understands the need for treatment. No SI or HI.
Impression:  
Emily presents with symptoms consistent with generalized anxiety disorder and major depressive disorder. Her anxiety and depressive symptoms are impacting her academic performance and social interactions.
Diagnosis:  
Generalized Anxiety Disorder, Major Depressive Disorder
Treatment Plan:  
1. Initiate cognitive-behavioral therapy (CBT) to address anxiety and depressive symptoms.  
2. Consider starting a low-dose SSRI if symptoms do not improve with therapy alone.  
3. Schedule family meetings to provide support and education.  
4. Follow-up appointment in four weeks to assess progress.  
5. Patient and family are aware to contact my office prior to our next appointment if any concerns or questions arise.
Safety Plan:  
Not applicable at this time.
This note was generated with the assistance of AI technology. It has been reviewed and edited for clarity. Appropriate explanation was given and consent obtained from patient/patient caregiver prior to use.