October 24, 2011
Swedish Edmonds Birth and Family Clinic
21911 76th Ave. W., Suite 110, Edmonds, WA 98026
Andrew K Smith
Male DOB: 06/06/1990
Patient Profile: 21 Year Male
Height: 66.75 inches
Weight: 136 pounds
Pulse rate: 80/minute
Resp: 12 per minute
BP sitting: 114/76 (right arm)
History of Present Illness:
Patient is here with mom. Had been feeling very depressed, lots of anxiety after moving to Pullman for school. Had suicidal thoughts, so saw doctor at WSU who started celexa and clonazepam about one month ago. Since started, has been feeling dizzy . . . Did not take celexa and clonazepam over the weekend because he was planning to drink. Still felt dizzy . . . Had some sleep disruption.
Due to medications, he had been avoiding social gatherings (where alcohol was available) at the advice of the doctor there, and this led to feeling even more isolated and alone.
Stressors: school, move to Pullman, planning for study abroad (Australia) . . . Depressed mood is better, no longer suicidal ideation, but still anxious.
Seeing counselor in Pullman . . . Had thoughts of wanting to “not be here,” wishing was dead. Never plan. Thinks never would hurt himself because of his family, “it would not be fair.” Still some passive death thoughts occasionally.
Impressions and Recommendations:
Review use of medications, recommended length of treatment, need to taper dose when discontinuing. Value of counseling, stress management and self care . . . Advised patient of side effects of both celexa and clonazepam . . . Advised him if side effects worsen to seek ER care promptly in between follow-ups there. Will set up follow-up with me as well over Thanksgiving weekend. No self harm contract discussed, and agreed upon. Continue counseling, recommended every week.