Jordan Avery (demo)
GAL-100482 · 36y · DOB 1990-04-12
Allergies
Sulfa drugs
Medications
2 active
Focus
somatic
PHQ-A
6 · mild
Last seen
2026-06-10
Problem list
- F41.1Generalized anxiety disorder· since 2024-09-02 · active
- F32.1Major depressive disorder, moderate· since 2025-01-15 · active
- G47.00Insomnia, unspecified· since 2025-02-10 · active
Medications
- Sertraline 50 mg — 1 tablet by mouth daily · since 2025-01-20
- Hydroxyzine 25 mg — 1 tablet at bedtime as needed for anxiety · since 2025-02-12
Screeners & vitals
2026-06-10
6
PHQ-9 · mild
2026-04-08
11
PHQ-9 · moderate
2026-01-14
16
PHQ-9 · moderately severe
PHQ-9 trending down (16 → 11 → 6) — the patient is improving.
Treatment plan
- Reduce PHQ-9 below 5 (remission) by the next quarterly review
- Re-establish a consistent sleep window; taper PRN hydroxyzine
- Weekly CBT skills practice — thought records between sessions
Next review · 2026-09-10
Most recent note — scribed by Gale, signed by the clinician
Reports sleep improving — 5–6 hrs most nights, fewer 3 a.m. wakeups. Work stress lower since boundary conversation. Denies SI.
Bright, engaged on video. Speech normal rate. PHQ-9 today 6 (was 11 in April). GAD-7 8. No acute distress.
GAD + moderate MDD, both improving on sertraline 50 mg + weekly CBT. Insomnia residual but better.
Continue sertraline 50 mg. Keep hydroxyzine PRN, encourage taper. CBT thought records weekly. RTC 4 weeks; re-screen at quarterly review.
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