Treatment Plan and Notes: S.J., a 16-year-old female patient, presented herself to the clinic at 9:25 AM, accompanied by her mother, P.J., and her nanny. S.J. was diagnosed with pediatric depression four months ago and has been on combined pharmacological and non-pharmacological therapy for the last three months

 Chief Complaint: S.J. visited the clinic at around 9:25 AM; the reason for the visit was an appointment with the pediatric psychiatrist regarding her monthly mental health check-up related to previously diagnosed pediatric depression. During the visit, S.J. was accompanied by her mother, P.J., and her nanny.
Practice Management:
The visit was to the Pediatric clinic. The overall check-up lasted for 45 minutes.

Diagnosis: Monthly check-up for pediatric depression. The patient scored 16 on the Children’s Depression Inventory-2 scale, indicating improvement.
Treatment Plan and Notes:
S.J., a 16-year-old female patient, presented herself to the clinic at 9:25 AM, accompanied by her mother, P.J., and her nanny. S.J. was diagnosed with pediatric depression four months ago and has been on combined pharmacological and non-pharmacological therapy for the last three months. She had visited the clinic to fulfil her fourth monthly mental health check-up related to the previous diagnosis of pediatric depression and ongoing medication and therapy management. S.J. did not report any concerns with the current treatment regimen; her mother noted that she had made major improvements.

During the visit, S.J.’s vitals, including blood pressure, heart rate, respiratory rate, and body temperature, were checked and noted to be within the normal ranges. She appeared well-groomed and well-dressed. She was also attentive and tried to connect with others in the clinic during her current visit as compared to her previous visits, in which she appeared shy and quite avoidant. She was well-oriented throughout the session and smiled from time to time. S.J. scored 16 on Children’s Depression Inventory-2 (CDI-2) test compared to the previous 28 scores on the CDI-2 scale. This is a notable improvement as compared to her initial assessment and the other preceding visits.

The S.J. will discontinue the fluoxetine dosage after completing the recommended 12-week medication period. However, she will be required to continue with cognitive behaviour therapy (CBT); she and her whole family will also attend five family therapy sessions. The family will also be required to continue providing a supportive environment to support S.J. throughout her recovery. The follow-up sessions will continue with the nanny, and S.J.’s mother will be required to be active in the sessions to provide support and reduce the risk of relapse