Dashboard

Below is the reformatted clinical note in a standardized template based solely on the provided information.

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Patient Information
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• Name: Alexis Brown
• Date of Service: 09/17/2025
• Provider: Amanda Lantow
• Specialty Code: 394800008
• Place of Service: 11 (Office, In-Person)
• Visit Type: Established Patient
• Telehealth: No

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Chief Complaint
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• Patient reports: “Last month was not a good month in any sense.”

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History of Present Illness (HPI)
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• Narrative:
– The patient is seen for follow-up psychiatric medication management in the setting of multiple significant stressors over the past month.
– The loss of her diabetic cat “Sissy” (6 years old) on August 11, 2025, due to illness (decreased appetite, excessive water intake, urinary/fecal incontinence) has greatly impacted her. She describes the cat as central to her daily routine—with multiple alarms set for care, not leaving the house because of the cat, and even taking the cat when dog sitting.
– The patient experienced her first adult grief and reports that since the pet’s death she “hasn't been good at all.” She also stopped taking her medications for several days after the loss.
– She reports waking in the middle of the night to check for her cat, even though she is aware the cat is no longer there.
– The patient experienced intrusive suicidal thoughts (e.g., “walk right out there” into traffic) immediately after leaving the veterinary office, but did not act on them.
– Additional stressors include family conflicts (with sister, aunt, and concerns regarding her hospitalized mother) and declining academic performance with feelings of embarrassment, low confidence, and being unable to form thoughts during assignments.

• Note: Specific details such as onset, location, duration, and severity were not explicitly stated beyond the narrative provided.

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Past Medical History (PMH)
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• Not explicitly provided in the current documentation.

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Review of Systems (ROS)
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• Psychiatric:
– Depression, anxiety, grief reaction, and history of suicidal ideation (passive, intrusive thoughts noted approximately one month ago).
• Sleep:
– Reports “not great” sleep with recurrent middle-of-the-night awakenings.
• Academic/Social:
– Declining academic performance, social isolation with family conflicts, and reliance on older neighbors for support.
• Other systems:
– No additional information provided.

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Physical Examination
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• Appearance: Patient present for in-person appointment
• Behavior: Engaged in conversation and forthcoming about experiences
• Speech: Normal rate and rhythm
• Mood: Depressed, grieving, and frustrated
• Affect: Distressed and tearful when discussing content
• Thought Process: Logical and goal-directed
• Thought Content: Historical report of intrusive suicidal ideation; no current active suicidal ideation
• Insight: Present – patient recognizes her grief process and difficulties
• Judgment: Intact – patient did not act on intrusive thoughts
• OCD Screening:
– Total Score: 4/40 (Subclinical)
– Obsessed Items: 4/20; Compulsions: 0/20
– Severity Band: Subclinical

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Assessment / Diagnosis
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1. Major Depressive Disorder
   – Worsened in the context of acute grief from pet loss, family stressors, academic pressures, and recent medication non-adherence.

2. Generalized Anxiety Disorder
   – Patient verbalizes significant anxiety.

3. Grief Reaction
   – Acute grief following the euthanasia of her diabetic cat on 08/11/2025; first adult experience of deep grief.

4. History of Suicidal Ideation
   – Passive ideation documented with no current active ideation.

5. Family Dysfunction
   – Ongoing significant interpersonal conflict with her sister and aunt, and concerns regarding her mother’s health communication.

6. Academic Difficulties
   – Declining performance and confidence associated with mood symptoms and situational stressors.

7. Sleep Disturbance
   – Poor sleep with middle-of-the-night awakenings; trazodone efficacy to be reassessed.

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Plan / Treatment
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• Medication Changes:
1. Discontinue Paroxetine (Paxil) via cross-taper protocol:
– Week 1-2: Reduce dose to 25 mg once daily (from current 50 mg daily)
– Week 3-4: Reduce dose to 12.5 mg once daily
– Then discontinue
2. Start Fluoxetine (Prozac) 20 mg daily in the morning (initiate when Paroxetine is reduced to 25 mg daily)
3. Continue current medications:
– Lamotrigine 100 mg
– Trazodone (efficacy to be assessed at next visit)
– Buspar
– Xanax as needed

• Prescriptions Sent:
– Paroxetine 25mg: 14-day supply (for taper)
– Paroxetine 12.5mg: 14-day supply (for taper)
– Fluoxetine 20mg: Daily
– Pharmacy: Walgreens on South Albany

• Safety Measures:
– Patient denied current suicidal ideation.
– Has access to Xanax for acute anxiety.
– Discussion of the grief process conducted.

• Follow-Up:
– Next appointment scheduled for October 22, 2025 at 12:30 PM
– Will reassess mood, anxiety, sleep, and response to fluoxetine.
– Plan to revisit trazodone efficacy and consider medication adjustments as needed.

• Patient Education:
– Emphasized the importance of medication adherence.
– Instructed to take fluoxetine in the morning to avoid insomnia.
– Explained the gradual taper strategy for Paxil to prevent discontinuation symptoms.
– Encouraged allowing a natural grief process.

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Additional Documentation
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• Informed Consent / Risk Assessment:
– Patient discussed risk factors including past suicidal ideation; current safety verified with denial of active suicidal thoughts.
• Signature/Date:
– Documentation includes the date of service (09/17/2025); provider signature/date not explicitly provided in the note.

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Quality Grade: High
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Additional Questions for Improvement:

1. Would additional structured details (e.g., exact onset, duration, and severity of symptoms) regarding the HPI improve clarity regarding the patient’s clinical course?
2. Is there further past medical history or additional review of systems data that might be relevant to document in this visit?
3. Would adding explicit physical examination vital signs or further corroborative details assist in a more complete exam documentation?

This reformatting has strictly used the provided information without adding any new data.