Centre for Sexual Medicine Consult template

Thank you for referring your patient for consultation. Sarah was seen for an initial assessment.

IDENTIFICATION:
Sarah, , female

CHIEF COMPLAINT:
Nightmares occurring almost every night, daytime anxiety, fatigue, and lack of motivation.

HISTORY OF PRESENTING COMPLAINT:
Sarah reports experiencing recurrent nightmares almost every night, which leave her feeling exhausted upon waking. She describes an increase in daytime anxiety, which she finds difficult to manage. Sarah also reports persistent fatigue and a lack of motivation, stating that even small tasks feel overwhelming. These symptoms have been ongoing and are significantly impacting her daily functioning and quality of life.

INVESTIGATIONS:

MEDICAL HISTORY:

SURGICAL HISTORY:

PSYCHIATRIC HISTORY:
Sarah is currently being treated with sertraline at a dose of 100 milligrams for her symptoms.

MEDICATIONS:
sertraline, 100 milligrams, daily, , 
prazosin, low dose, daily, , 

ALLERGIES:

SUBSTANCE USE:
1. Cigarettes: 
2. Cannabis: 
3. Alcohol: 
4. Other: 

PAST PERSONAL HISTORY:

MENTAL STATUS EXAM:
Sarah appeared alert and oriented to person, place, and time. Her mood was described as anxious and fatigued, with a congruent affect. Speech was normal in rate and tone. Thought processes were logical and goal-directed. No evidence of hallucinations, delusions, or other psychotic features was observed. Insight and judgment appeared intact.

IMPRESSION AND PLAN/RECOMMENDATIONS:
1. Post-traumatic stress disorder (F43.10): Characterized by recurrent nightmares and anxiety.
2. Major depressive disorder (F33.1): Associated with fatigue and lack of motivation.

Sarah is experiencing significant distress due to persistent nightmares, daytime anxiety, fatigue, and lack of motivation. These symptoms have been ongoing and are impacting her daily functioning and quality of life.

After meeting with the patient, we discussed the following:

1. Initiated prazosin at a low dose to address trauma-related nightmares and improve sleep quality.
2. Maintained the current dose of sertraline at 100 milligrams daily.
3. Discussed potential side effects of prazosin, including dizziness and the possibility of worsening dreams, and advised Sarah to contact the clinic if these occur.
4. Encouraged Sarah to monitor her symptoms and note any changes in anxiety, motivation, or energy levels.
5. Discussed the potential for adding bupropion in the future if fatigue and lack of motivation persist after improving sleep.
6. Scheduled a follow-up appointment in two weeks to assess the effectiveness of prazosin and overall symptom management.
7. Advised Sarah to reach out earlier if she experiences any adverse effects or worsening symptoms.

The above recommendations have been reviewed.

Please do not hesitate to contact me at xxx@xxx.xxx if you have any questions or concerns. Thank you for involving me in your patient’s care.