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Patient Information
- Patient Name: Adam Wallace  
- Date of Service: 01/28/2026  
- Provider NPI: 12  
- Provider Specialty Code: 394800008  
- Visit Type: In-person

Chief Complaint
Follow-up psychiatric medication management appointment for PTSD, depression, and anxiety. Patient is also requesting a trial of clonazepam for upcoming travel.

History of Present Illness (HPI)
Mr. Wallace is an adult male presenting for follow-up after his last appointment on February 3rd. He reports self-adjusting his aripiprazole dose from 2 mg to 4 mg since the last visit and is satisfied with the increase.

Depression:  
- Describes his depression as "a little better" compared to the previous visit.  
- Reports decreased feelings of apathy, improved enjoyment of activities, and increased engagement in his marriage.  
- Expresses hope that warmer weather will further improve his mood.

Suicidal Ideation:  
- Experiences fleeting, passive suicidal thoughts ("morbid thoughts about escaping from society" such as living in a car alone) that occur with decreased frequency.  
- Denies any intent or plan to act on these thoughts and states they are “easy to shake off.”

Emotional Reactivity/Irritability:  
- Feels more in control of his anger since increasing aripiprazole.  
- Indicates he is better able to reflect on his feelings before reacting, with only occasional, mild overreactions during arguments.

Anxiety/PTSD Symptoms:  
- Continues to struggle with crowds and experiences hypervigilance in busy settings, scanning for exits and conducting continuous threat assessments.  
- Endures flashbacks (primarily as nightmares) a couple of times per week with triggers including loud noises, bright light reflections, smells, truck brakes, and routine changes.  
- Experiences a prominent startle reflex and occasional feelings of unreality/dissociation a few times per week.  
- Baseline anxiety is manageable, although it escalates quickly with trauma-related triggers.  
- Panic attacks occur 0-1 times per week; grounding techniques and walking help alleviate these episodes.  
- Reports moderate racing thoughts, ruminations, and catastrophizing.

Work/Occupational Functioning:  
- Reports difficulty with concentration at his current desk job, particularly during periods of inactivity.  
- Expresses a desire for a more kinetic work environment and is seeking enrollment in the VA vocational rehabilitation program for career counseling and potential career change.

Sleep:  
- Noted improved sleep quality with a new CPAP machine and better tolerance of the new mask.  
- Sleeps approximately 6–8 hours per night with fewer interruptions.  
- Has been taking trazodone 50 mg at bedtime but is now agreeable to increasing the dose to 75 mg.

Energy/Motivation:  
- Improved energy attributed to better quality sleep.

Appetite/Weight:  
- Describes appetite as “okay.”  
- Tends to overeat and prefers poor snack choices high in salt, sugar, and carbohydrates.  
- Weight is stable despite a previous 30-pound gain over several years.  
- Hopes warmer weather will lead to increased activity and weight management.

Exercise:  
- Walks his dog 2–3 times daily (approximately 2–3 miles total).  
- Plans to increase walking distance and duration with longer daylight and warmer weather.

Past Medical History (PMH)
- Medical Conditions:  
  - Prediabetes  
  - Obstructive Sleep Apnea (currently using CPAP)
- Substance Use:  
  - Cigarettes: None  
  - Alcohol: Very rare use  
  - Marijuana: Uses typically morning and nighttime for pain and anxiety  
  - Caffeine: Consumes soda and energy drinks several days per week (currently attempting to reduce intake)
- Therapy:  
  - Ongoing therapy with Christie (reports a good therapeutic fit)

Review of Systems (ROS)
- Psychiatric: Depression, anxiety, PTSD symptoms, irritability, and passive suicidal ideation.  
- Sleep: Improved sleep quality with CPAP, sleeps 6–8 hours per night.  
- Appetite: Normal with tendency to overeat; cravings for salt, sugar, and carbohydrates.  
- Energy: Improved energy levels.  
- Neurological: Occasional flashbacks, startle reflex, and dissociative feelings.  
- Occupational: Difficulty concentrating and dissatisfaction with current work environment.

Physical Examination
 Mental Status Examination
- Appearance: Not documented  
- Behavior: Cooperative and engaged  
- Speech: Normal rate and rhythm, goal-directed  
- Mood: Not explicitly stated  
- Affect: Appropriate to content  
- Thought Process: Linear and logical  
- Thought Content: Endorses fleeting passive suicidal ideation without intent or plan; morbid thoughts about escaping present but decreased in frequency; no homicidal ideation noted  
- Perception: No active psychosis observed  
- Cognition: Intact based on conversation  
- Insight: Good—patient is aware of his symptoms and seeks treatment modifications  
- Judgment: Good—manages medications appropriately and is proactive in treatment

OCD Assessment
- Severity Band: Mild  
- Total Score: 10/40  
- Obsessions Subscore: 4/20  
- Compulsions Subscore: 6/20

Assessment / Diagnosis
1. Post-Traumatic Stress Disorder (PTSD):  
   - Persistent symptoms including hypervigilance, nightmares, flashbacks, dissociative episodes, and trauma-related triggers.  
   - Ongoing functional impairment in crowded settings.  
   - Some improvement in emotional reactivity following aripiprazole dose adjustment.

2. Major Depressive Disorder:  
   - Mild improvement in depressive symptoms with decreased apathy and increased engagement in life and relationships.  
   - Persistent fleeting passive suicidal ideation without intent or plan; overall improvement noted.

3. Generalized Anxiety Disorder:  
   - Manageable baseline anxiety with escalation during trauma-related triggers and moderate racing thoughts.  
   - Occasional panic attacks (0-1 per week) addressed with grounding techniques.

4. Irritability/Mood Dysregulation:  
   - Improved control over anger symptoms attributed to increased aripiprazole dose.

5. Obstructive Sleep Apnea:  
   - Improved sleep quality and compliance with the use of a new CPAP machine.

6. Prediabetes:  
   - Stable condition; weight is stable despite previous gain.

7. Obsessive-Compulsive Disorder (OCD) Symptoms:  
   - Mild symptoms based on assessment score (10/40).

Plan / Treatment
 Medications
1. Aripiprazole:  
   - Increase the dose from 2 mg to 5 mg daily in the morning.  
   - Patient has been self-adjusting to 4 mg with good effect; due to tablet availability, switching to 5 mg is indicated.  
   - Use remaining 2 mg tablets before transitioning to 5 mg.  
   - Sent to CVS at Target on Sycamore Road.

2. Trazodone:  
   - Continue 50 mg at bedtime.  
   - Patient may increase to 75 mg as discussed, with VA supplying the medication.

3. Sertraline:  
   - Continue 100 mg daily.  
   - Monitor for future need for adjustment; VA continues supply.

4. Clonazepam 0.5 mg: (New Prescription)  
   - Take 1–2 tablets as needed for travel anxiety (maximum 2 tablets per day).  
   - Dispense 30 tablets.  
   - Patient Education:  
     - Do not combine with alcohol, marijuana, or opioid/narcotic pain medications due to risk of respiratory depression, confusion, slowed processing, impaired gait, and increased fall risk.  
     - Onset is approximately 30–60 minutes with a duration of about 8 hours.  
     - If taking two doses in a day, space them at least 8 hours apart.  
     - For the first dose, remain in a safe location and avoid driving for 3–4 hours until effects are known.  
     - Avoid taking the first dose immediately before bed to assess daytime response.  
     - Benzodiazepines are for short-term, as-needed use only due to risks of tolerance, dependence, and misuse.  
     - Long-term use can disrupt sleep, lower mood, and increase anxiety; if daily use becomes necessary, reassessment of medications is warranted.

Therapy
- Continue ongoing therapy with Christie.

Follow-up
- Next appointment scheduled for Monday, July 14th at 5:30 PM (approximately 3 months from the visit).  
- Plan to reassess symptoms, review response to medication adjustments, evaluate the effect of seasonal change, and review plans prior to the August trip.

Safety and Risk Assessment
- Patient denies any suicidal intent or plan.  
- Passive suicidal ideation is fleeting and manageable.  
- Patient is encouraged to reach out if symptoms worsen or if any concerns arise before the next appointment.

Additional Documentation
- Informed Consent: Not explicitly documented but assumed from the treatment discussions and patient education provided, particularly regarding the new controlled substance (clonazepam).  
- Risk Assessment: Documented review of passive suicidal ideation, with clear patient report of no imminent risk.  
- Signature/Date: Documentation includes date of service 01/28/2026. (Provider signature not explicitly provided in the text.)

Quality Grade
Grade: High

Additional Questions for Improvement
1. Would additional details on the physical examination (e.g., vital signs, additional pertinent findings) be beneficial in future documentation?
2. Is further clarification on the patient’s mood (beyond affect) desired for enhanced clarity?
3. Would including explicit informed consent for medication changes improve documentation quality?

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