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Below is the reformatted clinical note following the requested standardized template:

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Patient Information

• Date of Service: 07/31/2025
• Place of Service: Office/Outpatient (11)
• Visit Type: New Patient
• Telehealth: No
• Patient Gender: Female
• Provider: Megan Becker
• Specialty: Psychiatry (394800008)

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Chief Complaint
Patient presents as a new patient requesting refills of propranolol and reporting increased anxiety and difficulty sleeping over the past week to two weeks.

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History of Present Illness (HPI)
Anne Zheng is a female patient here for an initial psychiatric evaluation. She reports needing a refill of propranolol 10mg, which she has been taking as needed for anxiety, primarily before presentations and social situations. Over the past one to two weeks, she has experienced increased nighttime anxiety with an elevated heart rate disrupting sleep. The medication, which she last refilled about a year ago, is still helpful for calming her symptoms when taken at night.

Additional details include:

• Onset & Timing: Symptoms worsened over the past one to two weeks.
• Duration: Multiple nights with difficulty falling asleep.
• Character: Increased anxiety at night associated with racing heart rate.
• Aggravating/Relieving Factors: Propranolol helps slow heart rate and reduce anxiety; she also uses propranolol before high-pressure social situations.
• Severity: Rates her current depression symptoms as 8/10 compared to her baseline of 2/10.
• Narrative: She describes a long-standing history of anxiety and depression with fluctuating symptoms. She also notes her menstrual cycle may sometimes affect her mood, with her last period beginning July 5th and an expected imminent onset of the next period.

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Past Medical History (PMH)
Psychiatric History

• Diagnoses: Anxiety and depression (previously diagnosed)
• Previous Medications and Responses:
  • Lexapro (escitalopram): Approximately 6 months use; ineffective.
  • Abilify (aripiprazole): Added for depression; caused excessive sedation and was discontinued.
  • Propranolol 10mg PRN: Currently in use with benefit for anxiety.
• Therapy: Limited brief therapy during college via university counseling services (not helpful) and currently not pursuing therapy.

Eating Disorder History

• History: Bulimia nervosa during college, onset around age 20.
• Current Status: In remission (last purging behavior over one year ago); continues behaviors such as daily calorie tracking and weighing.
• Additional Notes: Exercises extensively (up to three hours combining weightlifting and rock climbing).

Medical History (Other)

• Gynecological:
  • Abnormal Pap smear cells identified requiring biopsy (in Michigan).
  • Copper IUD placed five weeks ago.
• General Medical:
  • Denies other underlying health conditions.
  • Minor childhood surgery for a cut (no general anesthesia noted).
  • Last physical with bloodwork within the past year; last gynecologic appointment in January 2025.

Substance Use

• Alcohol: Approximately once monthly (social, one drink typical – White Claw).
• Caffeine: 100mg caffeine pill daily.
• Nicotine/Cannabis/Other: Denied.

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Review of Systems (ROS)

• Sleep: Difficulty falling asleep over the past one to two weeks due to anxiety and racing heart.
• Appetite: Decreased over the past month; patient consumes approximately 1,200 calories per day.
• Energy: Adequate for work though motivation for exercise is decreased.
• Constitutional: Denies other significant changes.

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Physical Examination
Mental Status Examination

• Appearance: Attended in person (no formal documentation available).
• Behavior: Cooperative and engaged during the interview.
• Speech: Normal rate and rhythm.
• Mood: Initially described as “okay,” later reported depressive symptoms rated at 8/10 over the past week.
• Affect: Appropriate to the content of the discussion.
• Thought Process: Linear, logical, and goal-directed.
• Thought Content: Endorses passive suicidal ideation (hopeless thoughts) without any plan or intent; reports negative self-talk and feelings of worthlessness/guilt related to her parents.
• Perceptions: Denies hallucinations and paranoia.
• Cognition: Alert and oriented; history is coherent.
• Insight and Judgment: Fair; recognizes symptoms and seeks treatment; identifies her brother as a supportive contact.

Vital Signs / Physical Measurements

• Height: 5'2" (self-reported)
• Weight: Approximately 107 pounds (self-reported)

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Assessment / Diagnosis
Anne Zheng is a female patient with ongoing issues of anxiety, depression, and a history of bulimia (currently in remission). Key points include her increased nightly anxiety and depressive symptoms, decreased motivation for activities other than work, passive suicidal ideation (without a specific plan), and the possibility of premenstrual dysphoric disorder (PMDD) due to cyclical mood changes.
Diagnostic List:

1. Generalized Anxiety Disorder
2. Major Depressive Disorder, Recurrent
3. Social Anxiety Disorder (performance type)
4. Possible Premenstrual Dysphoric Disorder (PMDD) – to be monitored through mood tracking
5. Bulimia Nervosa, in Remission
6. Initial Insomnia Secondary to Anxiety

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Plan / Treatment

Medications

1. Propranolol 10mg:

   • Refill provided.
   • Patient educated that it is non-habit forming and can be taken preventatively.
   • Advised to take at 7–8 PM nightly when anxiety is elevated rather than waiting for symptoms to begin (noting a 1–2 hour onset of action).

2. Sertraline (Zoloft) 25mg:

   • New prescription initiated for a trial of luteal phase dosing aimed at addressing possible PMDD.
   • Instructions: Take one 25mg tablet daily starting two weeks prior to the expected period, and continue until the period begins. If the period is delayed, continue until onset.
   • Recommendation: Take after dinner to reduce gastrointestinal upset; if sleep is affected, consider morning administration.
   • Side Effects Reviewed: Potential for stomach upset, headaches, and dry mouth; standard antidepressant warnings provided regarding suicide risk.

3. Hydroxyzine 10mg:

   • New prescription for PRN (as needed) use for acute anxiety and sleep difficulties.
   • Directions: Take 1–2 tablets as needed if propranolol is insufficient; patient informed it acts similarly to a stronger Benadryl and may cause drowsiness.

Patient Education and Lifestyle Recommendations

• PMDD:

  • Discussed the possibility of PMDD contributing to cyclical mood changes.
  • Encouraged use of a period-tracking app (e.g., My Calendar) for mood monitoring.
  • Reviewed treatment options including antidepressants and discussed implications regarding her non-hormonal copper IUD.

• Lifestyle and Diet:

  • Provided education on Mediterranean diet principles—focusing on omega-3 fatty acids, healthy fats, probiotics, and fiber.
  • Recommended a trial of magnesium glycinate 400mg at bedtime to support sleep and reduce anxiety (provider to send a link for a reputable brand).
  • Encouraged daily non-strenuous exercise (20–30 minutes of walking), particularly during periods of low motivation.

• Eating Disorder Monitoring:

  • Emphasized the importance of adequate caloric intake and balanced nutrition for energy, cognition, and mood regulation.
  • Advised that any escalation in body image concerns or calorie obsession should be discussed promptly.

Referrals/Recommendations

• Gynecologic Care:

  • Recommendation to establish care with a gynecologist, noting that Rush and UIC have PMDD specialists.

• Primary Care:

  • Advised patient to establish or maintain care with her primary care physician.

Safety Measures

• Patient denies active suicidal plan or intent; reports only passive suicidal ideation.
• Identified her brother as a primary support for safety if symptoms worsen.
• Instructed to contact the provider immediately if suicidal thoughts escalate.

Follow-Up

• Scheduled to return in approximately 6 weeks to evaluate response to sertraline luteal phase dosing (allowing for one full menstrual cycle on medication).
• Patient instructed to call and schedule the follow-up appointment.
• Prescriptions have been sent to Walgreens on Halsted (expected turnaround: 20-30 minutes).

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Additional Documentation

• Informed Consent & Risk Assessment:

  • The patient was informed about the risks and benefits of new medications including standard antidepressant warnings regarding suicidal ideation.
  • Safety was assessed through evaluation of passive suicidal ideation with no current plan; appropriate safety contacts were identified.

• Signature/Date:

  • Documentation completed by Megan Becker on 07/31/2025.

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Quality Grade
Grade: High Quality

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Additional Questions for Improvement

• Are any additional details regarding the physical examination (e.g., other neurological or cardiovascular findings) required?
• Is further clarification needed for the follow-up plan, such as specifying appointment time or modality?

Please advise if any further modifications or additional details are required.