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Clinical Notes

Below is the reformatted clinical note based on the provided checklist:

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Patient Information

  • Name: Chelsea Sarikas
  • Age/Sex: 26-year-old Female
  • Provider: Megan Becker
  • Specialty: 394800008
  • Date of Service: August 8, 2025
  • Visit Type: Established Patient
  • Place of Service: Office (11)
  • Telehealth: No

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Chief Complaint

Follow-up for OCD and medication management

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History of Present Illness (HPI)

The patient is a 26-year-old female with obsessive-compulsive disorder (OCD) presenting for a follow-up appointment approximately one month after an increase in her Prozac (fluoxetine) dosage. She describes her mood as "pretty normal" without noticeable flatness. The patient reports that work has been particularly stressful during this period, describing it as "a little crazy" and "nightmarish" due to additional responsibilities beyond her usual duties.

Key Details:

  • Onset & Duration: Symptoms noted over the past month following medication adjustment.

  • Character: OCD symptoms include increased negative intrusive thoughts about herself and her body image, specifically recurring thoughts about purchasing a scale.

  • Associated Behaviors: Notable hair picking behavior with one episode lasting approximately one hour, longer than her typical pattern.

  • Severity: Approximately 4 days over the past month have been worse than baseline.

  • Aggravating Factors: Increased work stress appears to be exacerbating her symptoms.

  • Relieving Factors: The new dose of Prozac, though she reports no noticeable improvement yet (acknowledging it is early in the adjustment process).

  • Additional Symptom Detail:

    • Eating/Body Image: Denies purging behaviors; appetite and eating habits remain "pretty normal." However, she feels not ready to engage with a nutritional referral given the risk of "weaponizing" nutritional guidance amid intrusive thoughts.
    • Anxiety: Elevated, noticeably related to occupational stress.
    • Sleep: Generally “pretty fine” with occasional difficulty falling asleep; she uses magnesium (200-400mg) nightly. She has not experienced significant improvement with magnesium and prefers not to resume hydroxyzine.

  • Medication Tolerability: Reports mild nausea during the first few days after the dose increase, which resolved.

  • Psychotherapy: Continues weekly therapy with Anna and has initiated additional trauma-focused sex therapy, having completed one session with plans for a second.

  • Relationship: Reports a good relationship with her boyfriend, despite some anxiety about a pending conversation regarding her OCD manifestations.

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Past Medical History (PMH)

  • Obsessive-Compulsive Disorder (OCD)
  • Anxiety Symptoms (related to occupational stress)
  • Body Image Concerns/Disordered Eating History (currently stable without active purging concerns)

Note: Additional historical details (e.g., other chronic illnesses) are not provided in the note.

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Review of Systems (ROS)

  • Psychiatric:

    • Mood: Reports stable mood ("pretty normal"), no flatness.
    • Intrusive Thoughts: Increased, negatively focused on self-image.
    • Anxiety: Elevated, particularly in relation to work stress.

  • Sleep:

    • Occasional difficulty initiating sleep but generally adequate sleep quality.

  • Gastrointestinal:

    • Transient mild nausea after Prozac dose increase (resolved).
    • Appetite: Remains normal.

  • Eating/Body Image:

    • No purging behaviors reported.

Other systems are not documented or are negative.

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Physical Examination

Encounter Type: In-person office visit

  • General/Behavior:

    • Appearance: Not formally documented
    • Behavior: Engaged appropriately in conversation

  • Mental Status Examination:

    • Speech: Normal rate and rhythm, appropriate.
    • Mood: Described by patient as "pretty normal"
    • Affect: Appropriate to content
    • Thought Process: Linear and goal-directed
    • Thought Content: Intrusive thoughts regarding body image and self-criticism; denies current suicidal or homicidal ideation.
    • Insight: Good; recognizes triggers and impact on OCD symptoms
    • Judgment: Good; actively engaged in treatment options

Vital signs and other physical exam findings were not provided in the clinical note.

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Assessment / Diagnosis

  1. Obsessive-Compulsive Disorder (OCD):

    • Status: Stable to slightly worsened; exacerbated by increased work stress.
    • Clinical Reasoning: Despite a recent increase in Prozac, the patient continues to experience intrusive thoughts and prolonged hair picking episodes.

  2. Anxiety Symptoms:

    • Status: Elevated, linked to occupational stress.

  3. Body Image Concerns with Intrusive Thoughts:

    • Status: Ongoing, contributes to overall OCD symptomatology.

  4. History of Disordered Eating:

    • Status: Stable; no active purging behaviors and nutritional referral deferred.

  5. Sleep Disturbance:

    • Status: Mild difficulty initiating sleep; managed with magnesium supplementation.

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Plan / Treatment

  1. Medication Management:

    • Fluoxetine (Prozac) 40mg:

      • Continue current dose with a one-month supply sent to the pharmacy.
      • Plan to reassess efficacy at the next visit.

    • Magnesium Supplementation:

      • Increase dosage to 400mg nightly.
      • Advise taking magnesium 1–2 hours before bedtime to optimize its effect for sleep initiation.

  2. Psychotherapy:

    • Continue weekly therapy sessions with Anna.
    • Continue trauma-focused sex therapy (approximately twice per month), given current scheduling constraints.

  3. Nutritional Referral:

    • Deferred at this time due to patient concerns about triggering intrusive thoughts.
    • Option to revisit in the future.

  4. Pharmacogenomic Testing:

    • Discussed GeneSight testing as an option for future medication adjustments.
    • Patient has been informed previously but has not completed testing.

  5. Monitoring:

    • Reassess symptoms in 6 weeks.
    • If there is no improvement in OCD symptoms by then, consider further dose increase of Prozac or a potential medication change, possibly guided by pharmacogenomic testing.

  6. Safety Measures:

    • Instruct patient to contact the provider if any concerns arise prior to the next appointment.

  7. Follow-up Appointment:

    • Telehealth follow-up scheduled for September 12, 2025, at 8:15 AM.

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Additional Documentation

  • Informed Consent: Obtained for ongoing treatment and any potential medication adjustments.
  • Risk Assessment: Patient denies suicidal or homicidal ideations. Continues to demonstrate good insight and judgment.
  • Signature/Date: Megan Becker, MD – August 8, 2025

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Quality Grade: A

Questions for Improvement:

  • Are any additional past medical or surgical history details available to further contextualize the patient’s overall health?
  • Would including current vital signs and physical exam details (if available) improve the comprehensiveness of the documentation?
  • Is there any additional information regarding the patient's functional status or daily living activities that may be relevant?

Please advise if further modifications or additional details are needed.