Encounter — Patricia Johnson

HPI: Patricia Johnson is a 50-year-old female presenting for psychiatric medication management and psychotherapy session (45 minutes). She has a history of major depressive disorder, recurrent, currently moderate. Reports persistent low mood, anhedonia, and difficulty concentrating at work over the past 3 weeks. Sleep disrupted — waking at 3 AM unable to return to sleep. Appetite decreased, 4 lb weight loss in past month. PHQ-9 score today: 14 (moderately severe). No suicidal ideation, no self-harm. Current medications: sertraline 150mg daily (increased from 100mg 6 weeks ago), trazodone 50mg HS PRN. PSYCHOTHERAPY (45 minutes): Conducted individual psychotherapy session focused on cognitive behavioral techniques. Reviewed thought records from past 2 weeks — identified 3 persistent negative automatic thoughts related to work performance. Practiced cognitive restructuring using evidence-based challenging. Introduced behavioral activation schedule targeting morning routine and social engagement. Discussed sleep hygiene modifications. Patient demonstrated good insight and engagement. MEDICATION MANAGEMENT: Reviewed sertraline response — partial improvement in anxiety symptoms but inadequate mood response at 150mg. Discussed options: increase sertraline to 200mg vs. augmentation with bupropion. Patient prefers dose increase first. Increased sertraline to 200mg daily. Continue trazodone PRN. Monitor for side effects. ASSESSMENT: 1. Major depressive disorder, recurrent, moderate (F33.1) — partial response to sertraline 150mg, increasing to 200mg 2. Insomnia related to depression — continue sleep hygiene, trazodone PRN PLAN: Return in 3 weeks for medication follow-up. Continue weekly psychotherapy. PHQ-9 at next visit. Safety plan reviewed — patient has emergency contacts and crisis line number.