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Patient Information

• Name: Anna Madsen
• Date of Birth: January 13, 1998
• Date of Service: September 18, 2025
• Provider: Molly Jahrling, NP
• Specialty Code: 394800008
• Visit Type: New Patient
• Place of Service: 02 (Telehealth)
• Telehealth: Yes

Chief Complaint Patient presents for psychiatric medication management following referral by her current therapist. She reports discontinuing long-term duloxetine treatment, which resulted in a period of significant anxiety and now presents with increased depressive symptoms.

History of Present Illness (HPI)

• Onset & Duration:
  • Patient tapered off duloxetine at the beginning of summer 2025 after approximately ten years of use.
  • Experienced approximately one month of severe anxiety following discontinuation.
• Location:
  • Not specifically localized; symptoms are generalized.
• Character & Severity:
  • Describes current mood as “kind of fine, kind of neutral” but with increased tearfulness, low energy, poor self-esteem, and feelings of hopelessness.
  • Reports occasional passive suicidal ideation which she dismisses.
• Aggravating/Relieving Factors:
  • Significant life stressor noted: moving in with her partner triggered initial anxiety symptoms.
  • Anxiety symptoms have since subsided.
• Narrative:
  • 27-year-old female with depression and anxiety (diagnosed in 2013).
  • Previously used duloxetine with seasonal dosing adjustments (20 mg in summer, 40 mg in fall/spring) and experienced beneficial effects on anxiety despite fatigue and grogginess.
  • Following medication discontinuation, she experienced severe anxiety (waking at 6 AM with difficulty breathing, inability to return to sleep, and panic) that resolved after about a month.
  • Currently endorses symptoms consistent with a major depressive episode and residual anxiety symptoms (physical manifestations include shoulder/neck tension, stomach problems, heart clenching) along with indecision and decreased motivation.

Past Medical History (PMH)

• Psychiatric History:
  • Major depressive disorder and generalized anxiety disorder (diagnosed 2013).
  • Prior psychiatric hospitalization in 2014 for suicidal ideation and panic attacks.
  • History of self-harm behaviors (cutting, burning, bruising, starving) approximately 10 years ago (occurred 1–3 times monthly).
  • History of restrictive eating in high school; current binge eating behaviors without compensatory behaviors.
• Psychiatric Medications:
  • Duloxetine: Used for ~10 years with seasonal dosing; recently discontinued.
  • Zoloft (sertraline): Brief trial (2–3 weeks) with possible exacerbation of symptoms.
  • Prozac (fluoxetine): Possible past trial (patient is uncertain).
• Medical History:
  • Polycystic ovary syndrome (PCOS).
• Allergies:
  • Peanuts – anaphylaxis
  • Tree nuts – anaphylaxis
  • Soy – gastrointestinal upset (mild)
  • Chickpeas – gastrointestinal upset (mild)

Review of Systems (ROS)

• General: No fever or weight changes reported.
• Sleep:
  • Obtains 7–8 hours of sleep nightly.
  • No trouble falling asleep; early morning awakening resolved by adjusting wake time to 6 AM.
• Appetite & Eating:
  • Good appetite; reports eating "constantly" with difficulty stopping even when full.
  • Endorses current binge eating behaviors.
• Energy:
  • Low energy, which is stated as her baseline.
• Concentration:
  • Reports concentration is “okay.”
• Exercise:
  • Walks approximately 5 miles daily and participates in 30 minutes of Pilates weekly.
• Diet:
  • Previously maintained a strictly healthy diet; now consuming more processed/fried foods since moving in with her partner.
• Other Systems:
  • Denies significant respiratory, cardiovascular, gastrointestinal (beyond stated), or neurological complaints.

Physical Examination

• General Appearance:
  • Appears appropriate for a telehealth visit.
• Mental Status:
  • Behavior: Cooperative and engaged during interview.
  • Psychomotor Activity: Within normal limits.
  • Speech: Normal rate, rhythm, and volume.
  • Mood: Described as “kind of fine, kind of neutral.”
  • Affect: Constricted.
  • Thought Process: Linear and goal-directed.
  • Thought Content:
    • Denies current active suicidal ideation.
    • Endorses occasional passive thoughts of not waking up which she dismisses; denies homicidal ideation and delusions.
  • Perceptions: No auditory or visual hallucinations.
  • Cognition: Alert and oriented; concentration grossly intact.
  • Insight and Judgment: Both rated as fair.
• Standardized Assessment:
  • OCD Assessment (Y-BOCS):
    • Severity Band: Subclinical
    • Total Score: 0/40
    • Obsessions: 0/20
    • Compulsions: 0/20

Assessment / Diagnosis

1. Major Depressive Disorder, Recurrent Episode, Moderate
   • Evidence: Depressed mood, anhedonia, low energy, poor self-esteem, hopelessness, increased frequency of crying, and decreased motivation. Seasonal worsening noted (worse in fall/winter).
2. Generalized Anxiety Disorder
   • Evidence: History of anxiety with physical symptoms (shoulder/neck tension, GI symptoms, heart clenching), indecision, and difficulty making decisions; recent exacerbation tied to cessation of duloxetine.
3. History of Self-Harm Behaviors
   • In sustained remission (last episode approximately 10 years ago).
4. Binge Eating Behaviors
   • Active issue warranting monitoring; associated with feelings of guilt.
5. Polycystic Ovary Syndrome (PCOS)
   • As per medical history.

Plan / Treatment Pharmacotherapy

• Desvenlafaxine (Pristiq) 25 mg:

  • Instruction: Take one tablet by mouth daily in the morning for four weeks, then increase to 50 mg daily.
  • Rationale: Selected for treatment of both depression and anxiety symptoms based on historical response to an SNRI.
  • Patient Education: Reviewed the importance of daily dosing and that therapeutic effects may take 4–6 weeks to manifest. Discussed possible side effects (insomnia, headache, gastrointestinal symptoms).

• Propranolol 10 mg:

  • Instruction: Take one tablet by mouth as needed for breakthrough anxiety symptoms.
  • Rationale: Intended to manage acute physical symptoms of anxiety during titration of desvenlafaxine.
  • Patient Education: Explained it is primarily a blood pressure medication that can ease the physical sensations of anxiety. Advised on signs of hypotension (e.g., dizziness) and the importance of gradual position changes.

Supplements Recommended

• Magnesium Glycinate:
  • Instruction: Take at bedtime.
  • Benefits: Aids in anxiety, sleep, bone health, and muscle recovery.
• Vitamin D:
  • Instruction: Continue current supplementation; verify dosing frequency (daily vs. weekly) as per bottle instructions.

Lifestyle Recommendations

• Continue current exercise regimen (daily walking and weekly Pilates).
• Discussed benefits of cardiovascular activity, strength training, and yoga in mental health.
• Recommended adherence to a Mediterranean diet and increased whole foods intake for brain health.
• Encouraged practicing self-compassion during depressive episodes.

Therapy

• Continue weekly therapy sessions with current therapist, Mackenzie Ergang.

Safety Measures

• Suicide and Homicide Risk:
  • Patient denies current active suicidal ideation, plan, or intent and denies homicidal ideation.
• Home Safety:
  • Denies weapons in the home; feels safe at home.
• Crisis Resources:
  • Crisis resources reviewed; instructions provided for contacting the office immediately if symptoms worsen.

Follow-Up

• Appointment:
  • Return visit scheduled for Thursday, October 16, 2025 at 8:00 AM via telehealth.
• Additional Instructions:
  • Patient provided office contact information for any questions or concerns prior to the follow-up appointment.
  • Instructed to contact the office sooner if symptoms worsen.

Prescriptions Sent

• Desvenlafaxine 25 mg: Sent to Mariano's on Lawrence Avenue.
• Propranolol 10 mg: Sent to Mariano's on Lawrence Avenue.

Additional Documentation

• Informed Consent & Risk Assessment:
  • Patient engaged in discussion regarding medication risks and benefits, as well as safety measures related to suicidal ideation.
• Provider Signature: Molly Jahrling, NP
• Date: September 18, 2025

Quality Grade: High-Quality

Additional Questions for Improvement:

1. Are there any additional vital signs or physical exam details (e.g., blood pressure, heart rate) that should be documented for clarity?
2. Would additional documentation on any follow-up laboratory evaluations be beneficial in future visits?