Clinical note · #7
Office & outpatient
Provider: Dr. Last Name, First Name, MD
Date: 10/26/2023
Patient Information
Name: Banner, Luke (imaginary Name)
Date of Birth: 03/12/1965
Sex: Male
Medical Record Number: 987654321
Chief Complaint
Mr. Banner being seen with scratches to his face, which have been reported by nursing staff to be a result of anxiety. He requested to be seen by the nurse manager due to these scratches. Notably, there are no signs of self-inflicted scratching elsewhere, and measures have been taken to reduce the risk of skin injury by trimming his nails.
Medical History:
Mr. Banner is currently receiving treatment for anxiety with the following medications: clonazepam, divalproex, olanzapine, and Abilify. He is stable on this medication regimen and is not scheduled for a medication review (GDR) at this time.
Objective Findings:
Upon examination:
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The patient is resting in his bed but can be easily awakened.
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He is nonverbal and non-responsive.
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Facial examination reveals symmetrical scratches with multiple dried scabs scattered across his face, including the forehead and cheeks. There is no apparent redness, swelling, or signs of infection.
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Mr. Banner is receiving tube feeds through his gastrostomy tube (GT).
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Abdomen is soft with no signs of distention.
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He appears comfortable and at ease.
Assessment and Plan
1. Continue Mr. Banner's current psychiatric medication regimen as directed, given his stability on these medications.
2. Add hydroxyzine 50 mg orally three times a day (TID) to his medication regimen for the next 10 days to address anxiety-related symptoms.
3. Evaluate Mr. Banner for any improvements in his anxiety-related symptoms during the treatment period.
Signed by the provider · 10/26/2023