Behavioral Health Follow-Up
Patient, 51 y/o female was seen by the behavioral health consultant for a follow-up visit.
Iinitially referred by Dr. Medina for problems related to Adjustment Disorder with Mixed
Anxiety and Depressed Mood on 06/27/13.
Primary medical conditions are Type 2 diabetes and high cholesterol , both wellcontrolled by oral medications.
Subjective: Pt reported she feels better now that she has medication (Cymbalta and
Klonapin), pt reports she feels more in control and as if she can cope with things. BHC
and pt reviewed possible avenues for treatment (i.e. smoking reduction, cognitive
restructuring, sleep hygiene). Pt decreased from 1 pkg cigarettes per day by smoking only
part of each cigarette. BHC provided praise and inquired if pt interested in smoking
cessation, pt is uninterested but will continue to try to decrease on her own. Pt would like
to work on sleep hygiene techniques today. Sleep hygiene techniques were reviewed and
handouts provided.
Progress on Previous Plan:
1. Pt will go pet store with ferrets 1x/week for pleasurable activity. – (In Progress – pt
went one time, too hot to take them again)
2. Pt will review handouts (vicious cycle of depression, anxiety disorders) – (Complete-pt
noted it does not take into account neuropathy. BHC and pt adapted some of pts
pleasurable activities to accommodate neuropathy)
3. In future appts, smoking cessation, cognitive restructuring, and sleep hygiene will be
introduced. Pt would also benefit from continued diabetic counseling re: nutrition as pt
reports eating little during the day and overeating at night. – (In Progress)
Objective: Pt denied SI/HI. Dysphoric mood with congruent affect. Despite pts. report
of medication effectiveness, distress reduction is not evident in objective screeners.
Current PHQ9: 14/27 (Moderate depression) Prior: 15/27
Current GAD-7: 11/21 (Moderate anxiety) Prior:10/21
Assessment: 309.28 Adjustment Disorder, mixed anxiety and depressed mood
Plan:
1. Pt will go pet store with ferrets 1x/week for pleasurable activity if not too hot or
work on aero garden.
2. Pt will go to pool for 1-2 hours at least once per week.
3. Pt will discard part of each cigarette.
4. Pt will review sleep hygiene tips.
5. Pt will keep sleep diary for 7 nights.
6. In future appts, smoking cessation and cognitive restructuring will be introduced.
Pt would also benefit from continued diabetic counseling re: nutrition as pt reports
eating little during the day and overeating at night.
Pt is scheduled for f/u appt in 2 wks.