Therapy and Medication Review Note

Summary

• 34 y/o F presents for combined therapy and med review; reports mild improvement in depressive symptoms since starting escitalopram 4 weeks ago, though persistent workplace anxiety remains.
• Addressed cognitive distortions regarding job performance; patient demonstrates strong insight and motivation to utilize CBT techniques.

Chief Complaint

• "I'm feeling a bit less down, but my anxiety at work is still overwhelming."

History of Present Illness (HPI)

• Reports 30% reduction in anhedonia and improved sleep onset since last visit on 14/03/2026. Continues to experience somatic anxiety (palpitations, muscle tension) on weekday mornings.
• Mood rated 6/10 (up from 4/10); daily functioning intact, though energy is depleted by 17:00.
• Recently assigned to lead a major Q2 project at her firm, increasing performance pressure and fear of failure.

Topics Discussed

• Workplace stress management, boundary setting with supervisors, and physiological grounding techniques.
• Reviewed progress toward treatment objective of reducing work-related rumination; patient successfully logged thoughts 4x this week.

Interventions Used

• Cognitive Behavioral Therapy (CBT) focused on cognitive restructuring of "all-or-nothing" and "catastrophizing" thoughts; psychoeducation on SSRI titration timelines.
• Patient engaged actively, successfully identifying alternative balanced thoughts during in-session roleplay.

Tests and Scores

• PHQ-9: 11 (down from 15 on 14/03/2026) - Moderate depression.
• GAD-7: 14 (unchanged from 14/03/2026) - Moderate anxiety.

Mental Status Exam

• Appearance: Well-groomed, appropriate business casual attire, appears stated age.
• Behavior: Cooperative, good eye contact, mild psychomotor agitation (leg bouncing) when discussing work.
• Mood/Affect: Mood "anxious"; affect constricted but congruent, brightens briefly at end of session.
• Thought Process/Content: Linear, logical, goal-directed. No delusions, hallucinations, or obsessions. Denies SI/HI.
• Cognition/Insight/Judgment: Alert and oriented x4. Memory intact. Insight and judgment are good.

Medications

• Current Medications: escitalopram (Lexapro®) 10 mg PO daily for MDD and GAD; hydroxyzine (Vistaril®) 25 mg PO Q6H PRN for acute anxiety.
• Patient-Reported Adherence: 100% adherence to daily escitalopram; takes hydroxyzine 1-2x weekly at night.
• Side Effects: Mild transient nausea during week 1 (resolved); reports daytime sedation if hydroxyzine is taken during work hours.

Assignments and Plan

• Assignments: Complete daily CBT thought record focusing on workplace triggers; practice box breathing for 5 minutes at 08:00 and 12:00 daily.
• Plan: Increase escitalopram (Lexapro®) to 20 mg PO daily to target residual anxiety and depressive symptoms. Continue hydroxyzine (Vistaril®) 25 mg PO Q6H PRN at bedtime only. RTC in 4 weeks for therapy and med check.

Safety Assessment

• Denies passive or active suicidal ideation, intent, or plan. Denies history or current urges of non-suicidal self-injury or harm to others. Low acute risk.
• Strong protective factors include supportive partner, stable housing, future-oriented mindset, and consistent engagement in care. Reviewed existing safety plan.

Follow-Up Email

• Hi Sarah, thank you for meeting with me today. Here is a summary of our next steps:
  • Medication Change: We are increasing your escitalopram (Lexapro®) dose to 20 mg once daily to help manage your ongoing anxiety. I have sent the new prescription to your pharmacy. Continue using hydroxyzine (Vistaril®) 25 mg as needed for anxiety, ideally in the evening so it doesn't make you sleepy at work.
  • Homework: Keep filling out your daily thought log when you feel stressed about your new project, and practice box breathing twice a day (morning and midday).
  • Red Flags: Please reach out immediately if you notice worsening mood, restlessness, severe side effects, or any thoughts of harming yourself.
• If you have any questions before our next visit in 4 weeks, please message me through the patient portal or call the clinic office at (312) 555-0192 between 08:00 and 17:00 Central Time. For after-hours emergencies, call 988 or go to the nearest emergency room.

Diagnostic Codes

• F33.1 Major Depressive Disorder, recurrent, moderate
• F41.1 Generalized Anxiety Disorder

Billing Codes

• ICD-10: F33.1, F41.1
• CPT: 99214 (Established patient office visit, moderate MDM), +90833 (Psychotherapy add-on, 30 minutes)

To-Dos

• e-Prescribe escitalopram (Lexapro®) 20 mg PO daily (30-day supply, 2 refills) to Walgreens #0492.
• Patient to schedule 4-week follow-up appointment at checkout for 09/05/2026 and complete daily thought records.