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Patient Information
- Name: Anna Madsen  
- Date of Birth: January 13, 1998  
- Date of Service: September 18, 2025  
- Provider: Molly Jahrling, NP  
- Specialty Code: 394800008  
- Visit Type: New Patient  
- Place of Service: 02 (Telehealth)  
- Telehealth: Yes

Chief Complaint
Patient presents for psychiatric medication management following referral by her current therapist. She reports discontinuing long-term duloxetine treatment, which resulted in a period of significant anxiety and now presents with increased depressive symptoms.

History of Present Illness (HPI)
- Onset & Duration:  
  - Patient tapered off duloxetine at the beginning of summer 2025 after approximately ten years of use.  
  - Experienced approximately one month of severe anxiety following discontinuation.
- Location:  
  - Not specifically localized; symptoms are generalized.
- Character & Severity:  
  - Describes current mood as “kind of fine, kind of neutral” but with increased tearfulness, low energy, poor self-esteem, and feelings of hopelessness.  
  - Reports occasional passive suicidal ideation which she dismisses.
- Aggravating/Relieving Factors:  
  - Significant life stressor noted: moving in with her partner triggered initial anxiety symptoms.  
  - Anxiety symptoms have since subsided.
- Narrative:  
  - 27-year-old female with depression and anxiety (diagnosed in 2013).  
  - Previously used duloxetine with seasonal dosing adjustments (20 mg in summer, 40 mg in fall/spring) and experienced beneficial effects on anxiety despite fatigue and grogginess.  
  - Following medication discontinuation, she experienced severe anxiety (waking at 6 AM with difficulty breathing, inability to return to sleep, and panic) that resolved after about a month.  
  - Currently endorses symptoms consistent with a major depressive episode and residual anxiety symptoms (physical manifestations include shoulder/neck tension, stomach problems, heart clenching) along with indecision and decreased motivation.

Past Medical History (PMH)
- Psychiatric History:  
  - Major depressive disorder and generalized anxiety disorder (diagnosed 2013).  
  - Prior psychiatric hospitalization in 2014 for suicidal ideation and panic attacks.  
  - History of self-harm behaviors (cutting, burning, bruising, starving) approximately 10 years ago (occurred 1–3 times monthly).  
  - History of restrictive eating in high school; current binge eating behaviors without compensatory behaviors.
- Psychiatric Medications:  
  - Duloxetine: Used for ~10 years with seasonal dosing; recently discontinued.  
  - Zoloft (sertraline): Brief trial (2–3 weeks) with possible exacerbation of symptoms.  
  - Prozac (fluoxetine): Possible past trial (patient is uncertain).
- Medical History:  
  - Polycystic ovary syndrome (PCOS).  
- Allergies:  
  - Peanuts – anaphylaxis  
  - Tree nuts – anaphylaxis  
  - Soy – gastrointestinal upset (mild)  
  - Chickpeas – gastrointestinal upset (mild)

Review of Systems (ROS)
- General: No fever or weight changes reported.
- Sleep:  
  - Obtains 7–8 hours of sleep nightly.  
  - No trouble falling asleep; early morning awakening resolved by adjusting wake time to 6 AM.
- Appetite & Eating:  
  - Good appetite; reports eating "constantly" with difficulty stopping even when full.  
  - Endorses current binge eating behaviors.
- Energy:  
  - Low energy, which is stated as her baseline.
- Concentration:  
  - Reports concentration is “okay.”
- Exercise:  
  - Walks approximately 5 miles daily and participates in 30 minutes of Pilates weekly.
- Diet:  
  - Previously maintained a strictly healthy diet; now consuming more processed/fried foods since moving in with her partner.
- Other Systems:  
  - Denies significant respiratory, cardiovascular, gastrointestinal (beyond stated), or neurological complaints.

Physical Examination
- General Appearance:  
  - Appears appropriate for a telehealth visit.
- Mental Status:  
  - Behavior: Cooperative and engaged during interview.  
  - Psychomotor Activity: Within normal limits.  
  - Speech: Normal rate, rhythm, and volume.  
  - Mood: Described as “kind of fine, kind of neutral.”  
  - Affect: Constricted.  
  - Thought Process: Linear and goal-directed.  
  - Thought Content:  
    - Denies current active suicidal ideation.  
    - Endorses occasional passive thoughts of not waking up which she dismisses; denies homicidal ideation and delusions.  
  - Perceptions: No auditory or visual hallucinations.  
  - Cognition: Alert and oriented; concentration grossly intact.  
  - Insight and Judgment: Both rated as fair.
- Standardized Assessment:  
  - OCD Assessment (Y-BOCS):  
    - Severity Band: Subclinical  
    - Total Score: 0/40  
    - Obsessions: 0/20  
    - Compulsions: 0/20

Assessment / Diagnosis
1. Major Depressive Disorder, Recurrent Episode, Moderate  
   - Evidence: Depressed mood, anhedonia, low energy, poor self-esteem, hopelessness, increased frequency of crying, and decreased motivation. Seasonal worsening noted (worse in fall/winter).
2. Generalized Anxiety Disorder  
   - Evidence: History of anxiety with physical symptoms (shoulder/neck tension, GI symptoms, heart clenching), indecision, and difficulty making decisions; recent exacerbation tied to cessation of duloxetine.
3. History of Self-Harm Behaviors  
   - In sustained remission (last episode approximately 10 years ago).
4. Binge Eating Behaviors  
   - Active issue warranting monitoring; associated with feelings of guilt.
5. Polycystic Ovary Syndrome (PCOS)  
   - As per medical history.

Plan / Treatment
 Pharmacotherapy
- Desvenlafaxine (Pristiq) 25 mg:  
  - Instruction: Take one tablet by mouth daily in the morning for four weeks, then increase to 50 mg daily.  
  - Rationale: Selected for treatment of both depression and anxiety symptoms based on historical response to an SNRI.  
  - Patient Education: Reviewed the importance of daily dosing and that therapeutic effects may take 4–6 weeks to manifest. Discussed possible side effects (insomnia, headache, gastrointestinal symptoms).

- Propranolol 10 mg:  
  - Instruction: Take one tablet by mouth as needed for breakthrough anxiety symptoms.  
  - Rationale: Intended to manage acute physical symptoms of anxiety during titration of desvenlafaxine.  
  - Patient Education: Explained it is primarily a blood pressure medication that can ease the physical sensations of anxiety. Advised on signs of hypotension (e.g., dizziness) and the importance of gradual position changes.

Supplements Recommended
- Magnesium Glycinate:  
  - Instruction: Take at bedtime.  
  - Benefits: Aids in anxiety, sleep, bone health, and muscle recovery.
- Vitamin D:  
  - Instruction: Continue current supplementation; verify dosing frequency (daily vs. weekly) as per bottle instructions.

Lifestyle Recommendations
- Continue current exercise regimen (daily walking and weekly Pilates).  
- Discussed benefits of cardiovascular activity, strength training, and yoga in mental health.  
- Recommended adherence to a Mediterranean diet and increased whole foods intake for brain health.  
- Encouraged practicing self-compassion during depressive episodes.

Therapy
- Continue weekly therapy sessions with current therapist, Mackenzie Ergang.

Safety Measures
- Suicide and Homicide Risk:  
  - Patient denies current active suicidal ideation, plan, or intent and denies homicidal ideation.
- Home Safety:  
  - Denies weapons in the home; feels safe at home.
- Crisis Resources:  
  - Crisis resources reviewed; instructions provided for contacting the office immediately if symptoms worsen.

Follow-Up
- Appointment:  
  - Return visit scheduled for Thursday, October 16, 2025 at 8:00 AM via telehealth.
- Additional Instructions:  
  - Patient provided office contact information for any questions or concerns prior to the follow-up appointment.  
  - Instructed to contact the office sooner if symptoms worsen.

Prescriptions Sent
- Desvenlafaxine 25 mg: Sent to Mariano's on Lawrence Avenue.  
- Propranolol 10 mg: Sent to Mariano's on Lawrence Avenue.

Additional Documentation
- Informed Consent & Risk Assessment:  
  - Patient engaged in discussion regarding medication risks and benefits, as well as safety measures related to suicidal ideation.  
- Provider Signature: Molly Jahrling, NP  
- Date: September 18, 2025

Quality Grade: High-Quality

Additional Questions for Improvement:
1. Are there any additional vital signs or physical exam details (e.g., blood pressure, heart rate) that should be documented for clarity?
2. Would additional documentation on any follow-up laboratory evaluations be beneficial in future visits?

Formatting

★★★★★5/5

The clinical note is comprehensive and detailed, including patient demographics, detailed HPI with timeline, past medical and psychiatric history, ROS, physical exam, clear assessment/diagnosis, and a well-structured treatment plan including pharmacotherapy, supplements, lifestyle recommendations, therapy details, safety measures, follow-up instructions, and prescriptions. This level of detail facilitates accurate medical coding, billing, and claims processing.

Queries

Are there any plans for follow-up laboratory evaluations relevant to PCOS or potential medication effects that should be documented for future coding accuracy [e.g., lab monitoring for metabolic effects]?

The patient's history mentions Polycystic Ovary Syndrome (PCOS) (ICD-10: E28.2), but there is no active management or discussion during this visit. Should we code PCOS as a secondary diagnosis or omit it from the current encounter coding?

The clinical documentation includes a history of self‐harm behaviors which are noted to be in sustained remission. Should we include this diagnosis (e.g., using a history code such as Z91.5) even though it is not actively managed during this encounter? Including it may impact the overall complexity of the mental health assessment.

Could you provide any additional vital signs (e.g., blood pressure, heart rate, respiratory rate) from the telehealth visit? This will help ensure complete documentation for codes [e.g., CPT codes for evaluation, diagnostic tests].

Primary Diagnosis

100% Confidence

F33.1 ICD-10-CM i

Major Depressive Disorder, Recurrent, Moderate (F33.1) is the chief complaint based on the patient's report of increased depressive symptoms, tearfulness, low energy, and hopelessness following discontinuation of duloxetine.

Other Diagnosis

100% Confidence

F50.81 ICD-10-CM i

Binge Eating Disorder (F50.81) is coded based on the current report of binge eating behaviors with associated feelings of guilt. This is being actively monitored.

100% Confidence

F41.1 ICD-10-CM i

Generalized Anxiety Disorder (F41.1) is included given the patient’s history and current symptoms of anxiety including physical manifestations (shoulder/neck tension, GI symptoms, heart clenching) noted in the exam.

Procedures

Payer Rules Evaluation

The provided payer rules pertain exclusively to endovenous ablation and ultrasound-guided foam sclerotherapy for symptomatic lower-extremity venous insufficiency. In this case, no procedure codes were supplied and the clinical documentation reflects a psychiatric evaluation with medication management, not a treatment for CVI or varicose veins. There is no mapping of any procedure code to the provided diagnosis codes (F33.1, F41.1, F50.81) because the services requested are not related to the conditions covered by the rules. Additionally, the specific documentation requirements (clinical presentation, duplex imaging, CEAP classification, and conservative therapy compliance) are not met. Prior authorization conditions and modifier requirements are also not applicable. Therefore, based strictly on the information provided, this claim does not meet the payer rules for procedures related to venous insufficiency.