Dashboard

Below is the reformatted clinical note in Markdown following the specified checklist. The quality grade for this documentation is High Quality. If any additional clarifications on specific time allocations for psychotherapy treatments or further vital sign documentation become available, please consider including these details to further enhance the note.

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Patient Information

• Date of Service: 05/08/2025
• Provider: Juliette Murphy (Specialty Code: 394800008)
• Place of Service: 11 (Office – In-Person)
• Visit Type: Established Patient
• Patient Gender: Female

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Chief Complaint Patient returns after approximately six months (last seen November 5th) at the urging of her partner. She states she "promised somebody to put more effort into getting better and get help."

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History of Present Illness (HPI)

• Narrative:
  The patient is an established female with a complex psychiatric history including depression, anxiety, ADHD, body image struggles, and trauma related to childhood abuse by her mother (currently estranged and under her aunt’s legal guardianship). She has previously experienced nightmares (up to 50% of nights), flashbacks, memory gaps, avoidance behavior, anger, irritability, and sudden mood changes.

• Onset & Timing:
  The current exacerbation is noted since the last visit (approximately six months ago) with recent significant stressors:

  • Loss of her friend group in late November.
  • A new relationship initiated in December accompanied by ongoing conflict (issues with partner’s parents and a friend whom she describes as “manipulative”).
  • Describes a cyclical pattern of building herself up only to feel that everything is “ripped out from under” her.

• Character & Severity:

  • Depression: Variable appetite with periods of decreased intake during acute stress and compensatory overeating, poor sleep (notably during relationship conflicts), feelings of existence solely for others, and questioning her self-worth.
  • Anxiety: High levels of anxiety exacerbated by relationship conflicts, with physical signs including shaking and heightened distress.
  • Trauma Symptoms: Frequent nightmares (including one that “fucked her up” this morning), dreams of peaceful death, and ongoing flashbacks/memory gaps.
  • Self-Harm: Visible scars and an episodic pattern of superficial and occasionally deeper cuts. The most recent episode occurred approximately 10 days ago.
  • Suicidal Ideation/Behavior: Passive suicidal thoughts with previous attempt (April 2025; a self-stabbing attempt that resulted in only a “little nick”). Although she states “death isn't an option” currently, she is distressed by feeling unable to live as herself.

• Aggravating/Relieving Factors:
  Aggravated by acute stress (e.g., relationship conflict, poor sleep) and temporarily relieved by engaging in activities such as martial arts, group participation, and outpatient therapy (currently with therapist “Jay,” though she reports limited benefit).

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Past Medical History (PMH)

• Major Depressive Disorder
• Generalized Anxiety Disorder
• Attention-Deficit/Hyperactivity Disorder (ADHD)
• Post-Traumatic Stress Disorder (PTSD) related to childhood abuse
• History of self-harm and a suicide attempt (April 2025)
• Elevated Hemoglobin (managed medically with aspirin; patient is concerned because of self-harm history and martial arts)

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Review of Systems (ROS)

• Psychiatric: Depression, anxiety, passive suicidal ideation, history of self-harm, nightmares, flashbacks, and mood instability.
• Sleep: Poor sleep with episodes of no sleep at all during conflicts, despite the use of alcohol and sleep medications during acute stress.
• Appetite: Variable fluctuations including both decreased and compensatory increased eating.
• Substance Use: Increased episodic alcohol use during stress (three bottles of vodka in one week during April) and situational marijuana use.
• Other Systems: No additional systems documented in the provided note.

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Physical Examination

• General Appearance:
  Patient appears fatigued and tearful with visible scars on her arms from self-harm.

• Mental Status Examination:

  • Behavior: Tearful (tissues offered), visibly anxious during session (shaking noted).
  • Speech: Coherent with appropriate rate and volume.
  • Mood: Described as “up and down”; patient did not state a specific mood.
  • Affect: Labile, anxious, and tearful.
  • Thought Process: Linear and goal-directed.
  • Thought Content: Passive suicidal ideation present with history of recent suicide attempt; no current active suicidal plan or intent.
  • Perception: Reports nightmares; no evidence of active hallucinations.
  • Cognition: Alert and oriented.
  • Insight: Fair; she recognizes the need for treatment and acknowledges that her coping mechanisms are unhealthy.
  • Judgment: Fair to poor given her history of high-risk behaviors.

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Assessment / Diagnosis

1. Major Depressive Disorder (Moderate to Severe):

   • Clinical Reasoning: Presenting with significant depressive symptoms, sleep disturbance, appetite fluctuations, passive suicidal ideation, history of self-harm, and a recent suicide attempt.

2. Post-Traumatic Stress Disorder (PTSD):

   • Clinical Reasoning: History of childhood abuse, ongoing nightmares, avoidance behavior, memory gaps, irritability, and emotional lability.

3. Generalized Anxiety Disorder (GAD):

   • Clinical Reasoning: Elevated anxiety especially in relation to relationship stressors.

4. Non-Suicidal Self-Injury:

   • Clinical Reasoning: Active pattern of self-harm with episodic cutting, visible scars, and recent episodes.

5. Suicide Attempt (April 2025):

   • Clinical Reasoning: History of a self-stabbing attempt with minimal physical injury yet significant psychological distress.

6. Substance Use (Alcohol and Cannabis):

   • Clinical Reasoning: Episodic binge drinking during acute stress and sporadic situational marijuana use.

7. Attention-Deficit/Hyperactivity Disorder (ADHD):

   • Clinical Reasoning: Documented history, although not the primary focus of this visit.

8. Elevated Hemoglobin:

   • Clinical Reasoning: Patient is on aspirin to manage this condition; she expresses concerns related to her risk of self-harm and participation in martial arts.

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Plan / Treatment Medication Management

• Initiate Vraylar (Cariprazine) 1.5 mg:
  • Instructions: Take one capsule by mouth at bedtime daily.
  • Target Symptoms: Depression, anxiety, and mood instability.
  • Counseling: Educated on taking the medication consistently at the same time each night; informed of common side effects (sedation, possible stomach upset, potential for activation/agitation) with an expected onset of effect in approximately 2 weeks.
  • Logistics: Medication samples provided to begin immediately; prescription sent to Walmart on Route 38.
  • Note: Prior authorization likely required and will be completed by the provider.

Therapy / Psychosocial

• Patient is currently seeing therapist “Jay” but reports limited benefit.
• Recommended to pursue trauma-focused therapy and EMDR at a different facility using a walk-in screening process when schedule permits.
• Encouraged to continue engagement in supportive groups and meaningful activities such as martial arts.

Safety Planning

• Patient declined inpatient or Partial Hospitalization Program (PHP) level of care.
• A safety plan was discussed:
  • Identification of support persons (partner and aunt)
  • Commitment to return for follow-up and contact the office if worsening symptoms or adverse medication effects occur.

Medical Coordination

• Elevated Hemoglobin:
  • Patient is on aspirin; she declined blood draws due to concerns about self-harm and blood loss.
  • Consider coordinating with her primary care provider regarding further management.

Follow-up

• Return Appointment:
  • Date/Time: Thursday, June 12, 2025 at 3:00 PM (approximately 5 weeks from today).
  • Purpose: Medication follow-up to assess tolerability and efficacy of Vraylar.

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Additional Documentation

• Risk Assessment:

  • Chronic Risk Factors: History of suicide attempt, prolonged self-harm, childhood trauma, substance use during stress, sleep disturbances, and passive suicidal ideation.
  • Acute Risk Factors: Recent suicide attempt (April 2025), recent self-harm episode (approximately 10 days ago), ongoing relationship conflict, poor sleep, and heightened anxiety.
  • Protective Factors: Engagement in treatment (partner and aunt support), current participation in activities (martial arts, group participation), and commitment to trying medication.

• Informed Consent:
  Patient provided informed consent for medication initiation and outpatient treatment. She expressed an understanding of both the potential benefits and risks associated with the treatment plan.

• Signature & Date:
  Provider: Juliette Murphy
  Date: 05/08/2025

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Quality Grade High Quality

Questions for Improvement

1. Would it be possible to document explicit psychotherapy minutes to clarify the amount of time spent on supportive interventions separate from E/M activities?
2. Can additional vital sign data or further physical examination details be obtained in future sessions to enhance the overall documentation of the clinical encounter?

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