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Clinical Notes

Patient Information

  • Patient Name: Conner Tidd
  • Age/Gender: 26-year-old Male
  • Date of Service: June 2, 2025
  • Provider: Maggie Schauer
  • Specialty: 394800008
  • Place of Service: Office (11)
  • Visit Type: New Patient
  • Telehealth: No

Chief Complaint Patient presents as a new patient seeking closer psychiatric medication management due to unsatisfactory results from his general practitioner’s management. He reports long wait times for appointments (approximately two months) and recent issues with medication adjustments.

History of Present Illness (HPI)

  • Onset & Duration:

    • PTSD diagnosed approximately 2.5–3 years ago following traumatic events during Marine Corps basic training at age 19.
    • Depression symptoms noted since age 17–18 with a recent significant depressive episode occurring about 2 months ago before going on medical leave.
    • Agoraphobia and generalized anxiety have been ongoing, with fluctuations in severity.

  • Location:

    • Trauma during basic training, with current symptoms manifesting in various settings; increased anxiety particularly when leaving home or driving.

  • Character & Severity:

    • PTSD:
      • Symptoms include auditory and visual hallucinations (stress-induced), flashbacks, hypervigilance in public, irritability, anger outbursts (with dissociative “leaving body” sensation), intrusive memories, emotional numbing, and short-term memory difficulties.
      • Hallucinations: Auditory (hearing his wife’s voice when she is not present) and visual (shadow figures, peripheral full figures) primarily related to high stress.
    • Depression:
      • Presents with nighttime feelings of worthlessness, difficulty experiencing positive emotions, and variable appetite.
    • Agoraphobia & Anxiety:
      • Significant anxiety when leaving the house and during driving.
      • History of panic attacks (currently absent).
    • Sleep Issues:
      • Maintains a strict sleep regimen; deviations may lead to near-insomnia episodes.
    • Self-harm/Suicidal Ideation:
      • Past suicidal ideation at age 19 and history of cutting (remitted for 4 years).
      • Intrusive thoughts of self-harm are present, but without intent, plan, or desire.

  • Aggravating/Relieving Factors:

    • Stress exacerbates PTSD symptoms (especially hallucinations).
    • Being at home and on medical leave is associated with improved symptom control.
    • Weekly therapy and coping strategies help mitigate anxiety and agoraphobia.

  • Narrative Summary:
    The patient’s PTSD began with traumatic experiences during Marine Corps basic training, where he faced extreme stress including threats to his safety. This followed into a chronic course of depression and anxiety that have been managed variably over time with medications and psychotherapy. Recently, a medication trial with Paxil while on a higher dose of Wellbutrin resulted in adverse effects. He remains on a stable regimen of Bupropion and utilizes adjunctive medications for mood stabilization and symptom control, though he feels current medications are not adequately targeting PTSD-specific symptoms.

Past Medical History (PMH)

  • Psychiatric:

    • Post-Traumatic Stress Disorder (PTSD)
    • Major Depressive Disorder
    • Agoraphobia
    • Generalized Anxiety
    • History of Panic Attacks
    • History of self-harm (cutting, in remission for 4 years)
    • History of possible hypomanic episodes prior to initiation of current medications (episodes lasted 1–2 days, not seen since medication management)

  • Neurological:

    • Two seizures approximately 5–6 months ago during periods of high stress (non-epileptic in description, lasted 2–3 minutes)

  • Medical:

    • No chronic medical conditions, head trauma, or surgeries

  • Medication Reactions:

    • Adverse reaction to Paxil when reinitiated with Wellbutrin 300mg regimen (hyperactivity, teeth grinding, inability to pay attention, constant “drunk feeling” lasting approx. 3 days)

  • Allergies:

    • No known drug allergies

  • Current Non-Psychiatric Medications:

    • None

  • Family History:

    • Mother: History of depression
    • Both parents: History of alcoholism

  • Social History:

    • Lives in an apartment in Milwaukee with his wife and three cats (Noodle, Meatball, Tater Tot)
    • Employed as an Operations Supervisor at FedEx (currently on medical leave for 2.5 months)
    • Married for 2 years; reports a supportive relationship with his wife
    • Uses marijuana to help with sleep, minimal alcohol (approximately one beer per week), one caffeinated drink per day, denies tobacco/nicotine
    • Religion: Jewish
    • Denies legal issues beyond minor speeding tickets
    • Good support system including his wife and weekly therapy with Hannah

Review of Systems (ROS)

  • General: No weight loss or fever reported
  • Psychiatric:
    • Mood disturbances (depression, irritability, anxiety)
    • PTSD symptoms including hallucinations, flashbacks, intrusive memories, emotional numbing
    • Suicidal ideation not present currently, though past ideation and self-harm behavior noted
  • Neurological:
    • History of seizures; short-term memory issues noted
  • Sleep:
    • Strict sleep regimen maintained; occasional near-insomnia if regimen disrupted
  • Cardiovascular, Respiratory, Gastrointestinal, Musculoskeletal, etc.: Not specifically discussed

Physical Examination

  • Appearance: Patient attended in-person, not formally documented
  • Behavior: Cooperative, engaged, and open in discussion
  • Speech: Normal rate and rhythm
  • Mood/Affect:
    • Mood not explicitly stated; patient reports feeling in a “better spot”
    • Affect appropriate to discussion
  • Thought Process: Linear and goal-directed
  • Thought Content:
    • Reports intrusive thoughts of self-harm (without intent, plan, or desire)
    • No suicidal or homicidal ideation
  • Perceptions:
    • History of auditory and visual hallucinations during high stress; not currently active
  • Cognition:
    • Alert and oriented; reports short-term memory difficulties
  • Insight & Judgment:
    • Both good; patient demonstrates understanding of his conditions and treatment needs
  • Vital Signs:
    • Not documented

Assessment / Diagnosis

  1. Post-Traumatic Stress Disorder (PTSD):

    • Diagnosis supported by history of trauma during Marine Corps training, accompanied by hallmark symptoms (hallucinations under stress, flashbacks, hypervigilance, irritability, intrusive memories, and memory issues). Current low-stress environment on medical leave offers partial control; however, high-stress conditions exacerbate symptoms.

  2. Major Depressive Disorder:

    • Chronic with onset in late adolescence. Residual symptoms include nighttime worthlessness, anhedonia, and variable appetite, with improvement noted on current medication regimen.

  3. Agoraphobia:

    • Ongoing anxiety when leaving home or driving; improved with therapy and coping skills.

  4. Generalized Anxiety Disorder:

    • Persistent anxiety that is less pronounced at home, with a history of intermittent panic attacks.

  5. History of Self-Harm (Cutting):

    • Remitted for 4 years; current intrusive thoughts are present without intent.

  6. History of Possible Hypomanic Episodes:

    • Prior to initiation of medications, episodes of elevated mood and reduced sleep were noted without significant functional impairment; no recent episodes.

  7. History of Seizures:

    • Occurred 5–6 months ago during high stress; requires monitoring given current medication (Bupropion 300mg) that may lower the seizure threshold.

Plan / Treatment

  1. Medication Adjustments:

    • Discontinue Lurasidone (Latuda) 40mg: Initiate a cross-taper schedule.
    • Initiate Brexpiprazole (Rexulti):
      • Recently FDA-approved for adjunctive treatment of PTSD.
      • Starter sample pack provided: 7 tablets of 0.5mg and 7 tablets of 1mg.
      • Titration Schedule:
        • Week 1: Latuda 20mg (half tablet) + Rexulti 0.5mg at night
        • Week 2: Latuda 20mg + Rexulti 1mg at night
        • Week 3: Discontinue Latuda, start Rexulti 2mg at night (two 1mg tablets)
      • Provided copay card for pharmacy use.
      • Patient advised to take with a small snack to mitigate nausea, and to be aware of potential sedation, akathisia, or activation side effects.
    • Continue Bupropion (Wellbutrin) 300mg daily:
      • Monitor for seizure activity given the patient’s recent history.
    • Continue Prazosin 1mg (up to 3mg as needed) for nightmares:
      • Use as needed based on symptom occurrence.
    • Continue Hydroxyzine 25mg as needed for anxiety:
      • Typically utilized for sedation at night or prior to outings where anxiety is anticipated.

  2. Therapy and Follow-Up:

    • Continue weekly talk therapy with Hannah (Ascension) and remain on the waitlist for EMDR.
    • Follow-Up Appointment:
      • Scheduled for Monday, July 14, 2025 at 9:30 AM.
    • Interim Check-In:
      • Provider will contact the patient via text around June 18 to assess medication tolerability before sending the full prescription.

  3. Pharmacy:

    • Genoa Pharmacy

  4. Patient Education & Safety:

    • Educated on the titration schedule and potential side effects of Rexulti.
    • Provided written instructions and a copay card.
    • Instructed to contact the provider via text (reply to appointment reminder) if any side effects or concerns arise.
    • Patient denies current suicidal or homicidal ideations and reports feeling safe at home with a supportive network.

Additional Documentation

  • Informed Consent:
    • Patient has been informed of the changes in medication regimen and potential side effects.
  • Risk Assessment:
    • Patient denies current suicidal ideation, plan, or intent. Intrusive thoughts of self-harm are acknowledged without associated risk.
  • Signature/Date:
    • Provider: Maggie Schauer
    • Date: June 2, 2025

Quality Grade and Feedback

  • Quality Grade: A
  • Questions for Improvement:
    • Are additional details needed regarding the patient’s physical examination (e.g., vital signs) at future appointments?
    • Would a more detailed breakdown of the titration schedule or specific follow-up parameters be helpful for continued monitoring?
    • Is there any additional documentation or areas of clarification required for ongoing risk assessments or informed consent procedures?

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