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Below is the reformatted clinical note based strictly on the provided information:

────────────────────────────── Patient Information

• Provider: Juliette Murphy
• Specialty: 394800008
• Date of Service: August 15, 2025
• Place of Service: Office (11)
• Visit Type: Established Patient
• Telehealth: No
• Patient Age: 26 years old
• Patient Gender: Male

────────────────────────────── Chief Complaint Patient presents for psychiatric medication management follow-up. (Last seen in March 2025)

────────────────────────────── History of Present Illness (HPI)

• Narrative:
  The patient reports an overall "status quo" with a day-to-day fluctuating mood. He describes feeling generally stable when he is “in control of his own thoughts” and maintains a positive outlook. However, as the day progresses—with phone calls, reminders from his girlfriend regarding tasks, and daily stressors—he experiences waves of low mood, irritability, and apathy of mild to moderate severity that are situational in nature. He denies suicidal ideation.

• Sleep:
  Reports variable sleep quality; uses a CPAP machine. Some nights he sleeps well while other nights he struggles to fall or stay asleep. He notes a correlation between stress levels and sleep quality. Previously, he used hydroxyzine 25mg PRN for sleep with good effect but has finished that prescription and is requesting a refill.

• Anxiety:
  Notices increased anxious feelings and is actively working on reframing negative thoughts. Denies panic attacks and reports improved coping skills.

• ADHD Symptoms:
  Currently taking Adderall XR 25mg in the morning (around 6:00-6:30 AM). He experiences benefits in focus, attention, and mood stability during the effective window but notes a decline in effect around 2:00 PM with a “crash” by 4:30 PM. He previously benefited from an immediate-release (IR) booster dose in the afternoon.

• Appetite:
  Reports decreased appetite (unchanged from previous visits) and late-night cravings for sweets.

• Additional Narrative Details:
  The patient is facing significant financial stress, legal and custody issues following a recent divorce, and has recently started therapy with a new therapist (Mike Lewis, PsyD). He also has plans for initiating a home workout routine once his son Arlo starts school. He is aware of upcoming changes, including a physical examination with lab work scheduled for August 27, 2025.

────────────────────────────── Past Medical History (PMH)

• Psychiatric History:
  • Medication management for ADHD, anxiety, and depressive symptoms
  • Previous trials:
    • Sertraline (up to 100mg)
    • Fluoxetine (discontinued due to fatigue)
    • Bupropion (Wellbutrin) was prescribed but never started
• Note: No additional past medical conditions are documented in this note.

────────────────────────────── Review of Systems (ROS)

• General: Reports stress related to life circumstances (divorce, financial stress).
• Psychiatric:
  • Mood: Fluctuating, situational low mood
  • Anxiety: Increased awareness of anxious feelings with effective coping strategies
  • Sleep: Variable quality; difficulty with sleep onset and maintenance on stressful nights, uses CPAP
  • ADHD: Symptoms managed during morning hours with medication, wearing off later in the day
• Appetite: Decreased with late-night sweet cravings

────────────────────────────── Physical Examination

• Vital Signs:

  • Blood pressure noted during a recent pediatric appointment for his son was described as “on the higher end of good” (if 10 points higher, it would be in the slightly elevated range).

• Mental Status Examination:

  • Appearance: Not documented
  • Behavior: Cooperative and engaged
  • Speech: Normal rate, rhythm, and volume
  • Mood: Described as “okay” with day-to-day variability
  • Affect: Appropriate and congruent
  • Thought Process: Linear and goal-directed
  • Thought Content: No suicidal or homicidal ideation
  • Perception: No abnormalities noted
  • Cognition: Alert and oriented
  • Insight/Judgment: Good – patient is aware of symptoms, engaged in treatment planning, and receptive to recommendations

────────────────────────────── Assessment / Diagnosis

1. Attention-Deficit/Hyperactivity Disorder (ADHD):

   • Partially controlled on current regimen with Adderall XR 25mg in the morning; however, the effect diminishes by mid-to-late afternoon. History of benefit from an IR booster dose.

2. Generalized Anxiety Disorder:

   • Mild, situational symptoms that are managed with cognitive coping strategies; no panic attacks reported and no daily anxiety medication currently required.

3. Depressive Symptoms:

   • Mild and situational in nature, likely related to ongoing financial stressors and life changes. No suicidal ideation.

4. Insomnia, Intermittent:

   • Variable sleep quality despite CPAP use; previously responsive to PRN hydroxyzine 25mg without next-day grogginess.

────────────────────────────── Plan / Treatment

• Medications:

  1. Adderall XR 25mg:

     • Continue current regimen (one tablet daily in the morning).
     • Refill to be sent to pharmacy; fillable on 9/6/25.
     • Patient to call the pharmacy to fill when ready.

  2. Adderall IR 15mg:

     • Resume as an afternoon booster dose.
     • New prescription sent to Walgreens on State Street, Geneva.

  3. Hydroxyzine 25mg:

     • Refill for PRN use for sleep on nights with consecutive poor sleep.
     • Prescription sent to Walgreens on State Street, Geneva.

• Counseling/Education:

  • Discussed the high sodium content in LMNT electrolyte drinks due to borderline blood pressure and concurrent stimulant use; advised monitoring sodium intake from other sources.
  • Discussed potential future anxiety medication options including Buspirone (with 2-3x daily dosing) and Lexapro (effective for anxiety at lower doses, also aiding mood).
  • Encouraged initiation of a home workout routine as planned.
  • Requested that the patient share the upcoming bloodwork results from his full physical exam on 8/27/25.
  • Discussed recommended labs including CMP, CBC, thyroid, B12, vitamin D, A1C, and testosterone.

• Coordination of Care:

  • Patient signed a release of information for communication with his new therapist, Mike Lewis, PsyD, in Naperville.
  • Plan to coordinate medication management with his therapist as needed.
  • Patient to update the provider on any recommendations from the therapist at the next visit.

• Follow-Up:

  • Next appointment scheduled for Friday, September 12, 2025 at 10:30 AM.
  • Patient to relay today’s discussion to the new therapist.
  • Consideration to discuss initiation of an anxiety medication pending therapist input.

────────────────────────────── Additional Documentation

• Informed Consent / Risk Assessment:

  • Informed consent for treatment was obtained (documentation of the signed release for therapist communication is noted).
  • Risk assessment regarding mood fluctuations and medication management was addressed during the visit.

• Signature / Date:

  • (Electronic signature/documentation as per standard protocol; specific signature and date details are not provided in the note.)

────────────────────────────── Quality Grade Quality Grade: High

────────────────────────────── Additional Questions for Improvement

1. Would additional clarification regarding the duration and frequency of mood fluctuations further enhance the HPI?
2. Are there any documented past medical conditions or additional psychiatric history details (beyond medication trials) that should be integrated into the PMH section?
3. Should explicit vital sign values (e.g., exact blood pressure reading) be recorded for future visits to better quantify changes?