BIRP Note

Behavior

• Patient presented on time for the 14:00 session, casually groomed. Mood was reported as "anxious and overwhelmed" regarding recent job loss. Affect was constricted and congruent with mood. Psychomotor agitation was observed via frequent leg shaking and hand-wringing. Speech was normal in rate, rhythm, and volume. Denies SI/HI, auditory or visual hallucinations.

Intervention

• Conducted a 45-minute supportive psychotherapy and medication management session. Utilized CBT techniques to challenge catastrophic thinking related to financial stressors. Reviewed current medication regimen, noting partial response to escitalopram (Lexapro®) 10 mg PO daily. Initiated a cross-titration plan, increasing escitalopram to 20 mg PO daily and prescribing hydroxyzine (Vistaril®) 25 mg PO TID PRN for acute anxiety. Provided psychoeducation on potential side effects and sleep hygiene strategies.

Response

• Patient was receptive to cognitive reframing exercises and demonstrated good insight into anxiety triggers. Visibly relaxed by the end of the session, with cessation of leg shaking. Expressed agreement with the medication adjustment and verbalized understanding of the safety plan and PRN medication usage.

Plan

• Continue escitalopram 20 mg PO daily and hydroxyzine 25 mg PO TID PRN anxiety. Patient to complete daily thought records focusing on cognitive distortions. Referred to in-house clinical social worker for vocational rehabilitation resources. Follow-up appointment scheduled in 4 weeks on 12/05/2026 at 14:00 CST to assess medication efficacy and symptom progression. Instructed to contact the clinic or go to the nearest ED if acute safety concerns arise.