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Reformatted Clinical Note

Patient Information

• Date of Service: 09/12/2025
• Provider: Juliette Murphy
• Specialty: 394800008
• Place of Service: 02 (Telehealth)
• Visit Type: Established Patient
• Patient Gender: Male

Chief Complaint Follow-up appointment for medication management of ADHD, depression, and anxiety.

History of Present Illness (HPI)

• Onset & Duration: Approximately one month since the previous appointment.
• Narrative: The patient, an established male patient, reports his mood has been good overall despite a busy month filled with his children’s sports activities (softball and baseball).
• ADHD Symptoms and Medication:
  • Medication Regimen:
    • Adderall XR 25mg daily in the morning (around 6 AM) with reported efficacy through early afternoon.
    • Adderall IR used as an afternoon booster approximately 4-5 days per week as needed.
  • Symptom Details:
    • Days when the XR is inadequate are attributed to increased busyness, poor sleep, or higher stress levels.
    • Occasionally, the patient feels it is too late (around 4 PM) to take the afternoon booster.
    • Initially experienced difficulty obtaining the booster due to pharmacy ordering issues.
  • Insurance: Not covering medications due to out-of-network provider; patient is using GoodRx.
• Depression/Anxiety:
  • Mood: Mood is reported as "good" and "status quo"; mild depressed mood, sadness, and reduced enjoyment persist in the background.
  • Therapy: The patient is working with a new therapist (Dr. Mike Lewis) biweekly.
• Sleep:
  • Medication & Effects: Uses hydroxyzine approximately 4 nights per week before bed. Sleep is reported as "pretty good" with deeper sleep noted when on hydroxyzine, although there is some morning grogginess.
  • CPAP: Continues regular use.
• Recent Primary Care Visit (08/27/2025):
  • Findings:
    • Comprehensive blood work was within normal limits except for low testosterone (209) and low vitamin D3 levels.
    • Blood pressure and cholesterol were within normal limits.
  • Recommendations: Advised colonoscopy scheduling and exploration of natural supplements for testosterone support.

Past Medical History (PMH)

• Documented Conditions:
  • ADHD
  • Depression
  • Anxiety
• Additional Historical Details: Not further specified in the provided notes.

Review of Systems (ROS)

• General: No significant changes noted; overall feeling “good.”
• Neurological/Psychiatric:
  • ADHD well-managed with current regimen.
  • Mild persistent depression and anxiety with no acute exacerbations.
• Sleep: Reports good sleep quality with supportive measures (hydroxyzine and CPAP).
• Endocrine: Low testosterone and vitamin D3 per recent primary care lab reports.
• Other Systems: Not documented.

Physical Examination

• Telehealth Observation:
  • Patient appeared on video and engaged appropriately in conversation.
  • Minor technical difficulties resolved after re-signing into the session.
• Vital Signs:
  • Blood pressure noted as "good" based on recent primary care evaluation (specific numbers not provided).
• OCD Assessment:
  • Severity Band: Subclinical
  • Total Score: 0/40 (Obsessions: 0/20, Compulsions: 0/20)
• Laboratory Results (from 08/27/2025):
  • Testosterone: 209 (low)
  • Vitamin D3: Low
  • Cholesterol and other labs: Within normal limits

Assessment / Diagnosis

1. Attention-Deficit/Hyperactivity Disorder (ADHD):
   • Stable on current medication regimen (Adderall XR with as-needed IR booster).
   • Considerations based on patient’s report of activity levels and timing of medication doses.
2. Depression:
   • Mild, stable.
   • Current management includes biweekly therapy sessions and medication coordination.
3. Anxiety:
   • Managed with hydroxyzine as needed.
   • No acute exacerbation noted.
4. Sleep Disturbance:
   • Improved with hydroxyzine and regular CPAP use.
5. Low Testosterone:
   • Lab value of 209 noted; primary care provider provided educational materials regarding natural supplementation.
6. Vitamin D Deficiency:
   • Recently initiated over-the-counter supplementation.

Plan / Treatment

1. ADHD/Medication Management:
   • Continue Adderall XR 25mg daily in the morning.
     • Prescriptions scheduled for refills approximately on October 3 and then at 28-day intervals (next refill in November).
   • Continue Adderall IR as needed in the afternoon (4-5 days per week).
     • Next fill to be sent with a refill date of November 29; patient to contact the pharmacy when ready.
2. Depression/Anxiety:
   • Continue current management; defer any changes in medications.
   • Maintain biweekly therapy with Dr. Mike Lewis.
3. Sleep:
   • Continue hydroxyzine as needed (up to 2 tablets per day as previously prescribed) and adhere to CPAP use.
4. Supplements / Laboratory Follow-up:
   • Continue vitamin D supplementation.
   • Utilize educational materials regarding natural supplements for testosterone support.
5. Coordination of Care:
   • Therapies are provided by separate clinicians; coordination remains in place.
   • Follow up regarding recommendations from primary care (colonoscopy scheduling).
6. Follow-Up Appointment:
   • Scheduled for December 12, 2025 at 11:00 AM (Telehealth).
7. Patient Instructions:
   • Continue the current medication regimen as prescribed.
   • Maintain regular CPAP use.
   • Monitor symptoms and contact the provider should there be any worsening of depression or anxiety symptoms.
   • Call the pharmacy when ready for Adderall refills.
   • Consider changing to an in-network insurance plan in November if possible.

Additional Documentation

• Informed Consent / Risk Assessment: Not explicitly documented.
• Patient Signature / Date: Not provided in the notes.

Quality Grade: High

Questions for Improvement

1. Would additional explicit documentation of past medical history or review of systems be beneficial for future visits?
2. Should the total time of the visit and a clear provider credential be additionally documented for E/M billing purposes?
3. Is there a need for further elaboration on the patient's social and family history in upcoming visits?