Encounter Date Assessment Date Assessment LastModified by Organization Details LastModified Time

10/27/2025 10/27/2025

MEDICAL HISTORY: Colon cancer - stave 4. Anemia. Hypothyroidism. Renal impairment.

CURRENT ASSESSMENT:

On intake, patient presents with established treatment and no mood complaints, although does endorse some anxiety when he considers mortality. States he was given 1 year to live 1.5 years ago.

Patient currently completing PhD in computer science. Denies history of hospitalization or adverse life events.

RISK/SAFETY:

Denies SIHISIB, endorses having many things to accomplish, AVH, new or increased use of substance of abuse.

Endorses history of alcohol use in remission since 2015.

MEDICATION MANAGEMENT:

• continue Lorazepam 0.5mg PO daily PRN for breakthrough anxiety.

Zolpidem 5mg tablet PO daily PRN for sleep.

VITALS: UTA

LABS: 4/2025

• UDS: 10/28/25

REFERRALS: none

PLAN/DISCUSSION: continue current treatment plan

Discussed with patient plan to take over medications once UDS complete. Patient will present to clinic for UDS. Will continue treatment

Patient is encouraged to adhere to prescribed medication regimen to ensure optimal efficacy. Patient advised to contact provider before discontinuing any medication, particularly if adverse symptoms occur.

Psychoeducation and brief supportive counseling were provided.

Encouraged engagement with therapy; referrals will be made if necessary

Encouraged to follow up with medical provider if necessary

Discussed importance of nutrition, exercise, and sleep hygiene.

Discussed r/b, side effects, alternatives of _____, or choice to forgo pharmacological treatment with patient. Patient agreed to start trial.

CONSENT: Patient was given opportunity to ask questions and has verbally consented to the current treatment plan and any recommended changes.

Encouraged to seek care at ED if SI/HI with plan/intent develops or to call office if symptoms worsen

RELEVANT HISTORY:

nbennett54 Not available 10/29/2025 22:52:17

11/25/2025 11/25/2025

MEDICAL HISTORY: Colon cancer - stave 4. Anemia. Hypothyroidism. Renal impairment.

CURRENT ASSESSMENT:

11/25/25 - Patient presents with no pervasive mood concern.

RELEVANT HISTORY

On intake, patient presents with established treatment and no mood complaints, although does endorse some anxiety when he considers mortality. States he was given 1 year to live 1.5 years ago.

Patient currently completing PhD in computer science. Denies history of hospitalization or adverse life events. Discussed with patient plan to take over medications once UDS complete. Patient will present to clinic for UDS. Will continue treatment

RISK/SAFETY:

Denies SIHISIB, endorses having many things to accomplish, AVH, new or increased use of substance of abuse.

Endorses history of alcohol use in remission since 2015.

MEDICATION MANAGEMENT:

• continue Lorazepam 0.5mg PO daily PRN for breakthrough anxiety.

Zolpidem 5mg tablet PO daily PRN for sleep.

VITALS: VSS

LABS: 4/2025

• UDS: 10/28/25

REFERRALS: none

PLAN/DISCUSSION: continue current treatment plan

Patient is encouraged to adhere to prescribed medication regimen to ensure optimal efficacy. Patient advised to contact provider before discontinuing any medication, particularly if adverse symptoms occur.

Psychoeducation and brief supportive counseling were provided.

Encouraged engagement with therapy; referrals will be made if necessary

Encouraged to follow up with medical provider if necessary

Discussed importance of nutrition, exercise, and sleep hygiene.

Discussed r/b, side effects, alternatives of _____, or choice to forgo pharmacological treatment with patient. Patient agreed to start trial.

CONSENT: Patient was given opportunity to ask questions and has verbally consented to the current treatment plan and any recommended changes.

Encouraged to seek care at ED if SI/HI with plan/intent develops or to call office if symptoms worsen

RELEVANT HISTORY:

nbennett54 Not available 11/25/2025 09:27:47

01/26/2026 01/26/2026

MEDICAL HISTORY: Colon cancer - stave 4. Anemia. Hypothyroidism. Renal impairment.

CURRENT ASSESSMENT:

1/26 - No pervasive mood complaint or concern.

RELEVANT HISTORY

On intake, patient presents with established treatment and no mood complaints, although does endorse some anxiety when he considers mortality. States he was given 1 year to live 1.5 years ago.

Patient currently completing PhD in computer science. Denies history of hospitalization or adverse life events. Discussed with patient plan to take over medications once UDS complete. Patient will present to clinic for UDS. Will continue treatment

11/25/25 - Patient presents with no pervasive mood concern. Denies SIHISIB, endorses having many things to accomplish, AVH, new or increased use of substance of abuse. Endorses history of alcohol use in remission since 2015.

RISK/SAFETY:

Denies SIHISIB, AVH, new or increased use of substances

MEDICATION MANAGEMENT:

• continue Lorazepam 0.5mg PO daily PRN for breakthrough anxiety.

Zolpidem 5mg tablet PO daily PRN for sleep.

VITALS: UTA

LABS: 4/2025

• UDS: 10/28/25

REFERRALS: none

PLAN/DISCUSSION: C ontinue current treatment plan

Patient is encouraged to adhere to prescribed medication regimen to ensure optimal efficacy. Patient advised to contact provider before discontinuing any medication, particularly if adverse symptoms occur.

Psychoeducation and brief supportive counseling were provided.

Encouraged engagement with therapy; referrals will be made if necessary

Encouraged to follow up with medical provider if necessary

Discussed importance of nutrition, exercise, and sleep hygiene.

Discussed r/b, side effects, alternatives of _____, or choice to forgo pharmacological treatment with patient. Patient agreed to start trial.

CONSENT: Patient was given opportunity to ask questions and has verbally consented to the current treatment plan and any recommended changes.

Encouraged to seek care at ED if SI/HI with plan/intent develops or to call office if symptoms worsen

RELEVANT HISTORY:

nbennett54 Not available 01/27/2026 13:59:54