NF GP patient review template

Telehealth appointment date: 1 November 2024 Present: Dr. Thomas Kelly, [Patient Name], and [Parent/Guardian Name] Diagnoses/problem list: * Major Depressive Disorder, recurrent, moderate severity * Generalised Anxiety Disorder * ADHD, combined presentation Current medications: * Sertraline 100mg daily * Methylphenidate 20mg twice daily Previous medications: * Fluoxetine - ceased due to side effects of nausea and insomnia. * Venlafaxine - ceased due to lack of efficacy. Current supports: * Weekly therapy with Dr. Sarah Jones, Psychologist. * School counsellor, [School Name], meeting monthly. * Parental support from [Parent/Guardian Name]. Objective: * Weight: 65kg, Height: 160cm, BMI: 25.4 Summary: "[Patient Name]" was reviewed by telehealth with [Parent/Guardian Name] present for a follow-up appointment regarding mood and ADHD symptoms. Last appointment was on 1st October 2024. Since then, there has been a slight improvement in mood, with fewer depressive episodes. ADHD symptoms remain a significant challenge. Patient reports improved mood and reduced anxiety symptoms since the last review. There has been a slight improvement in concentration, but still struggles with impulsivity and hyperactivity. ADHD symptoms include inattention, hyperactivity, and impulsivity. Methylphenidate has shown some benefit, but the dose may need to be adjusted. No major side effects were reported. Patient reports difficulty with completing homework assignments and social interactions. These challenges were discussed, and strategies were reviewed. Mental state examination: Engagement: Cooperative and engaged. Appearance: Appropriate for age. Behaviour: Restless, fidgeting. Speech: Normal rate and rhythm. Mood: Elevated, but with some lability. Affect: Congruent with mood. Thought process: Linear and goal-directed. Thought content: No suicidal ideation or homicidal ideation. Perception: No hallucinations or delusions. Insight: Aware of symptoms. Judgement: Good. Cognition: Intact. Impression: [Patient Name] presents with a complex presentation of Major Depressive Disorder, Generalised Anxiety Disorder, and ADHD, combined presentation. DSM-5 criteria are met for all diagnoses. The patient's symptoms significantly impact daily functioning, particularly in academic and social settings. The patient demonstrates strengths in their willingness to engage in therapy and adhere to medication regimens. Differential diagnoses include Bipolar Disorder, which was ruled out based on the absence of manic episodes. Symptoms significantly impact daily functioning, particularly in academic and social settings. Overall functioning is moderate, with a guarded prognosis. The patient demonstrates strengths in their willingness to engage in therapy and adhere to medication regimens. There were no immediate risks identified. Today we discussed: * Review of current medications and potential dose adjustments. * Continued therapy with Dr. Jones. * Strategies for managing ADHD symptoms at school and home. Recommendations for GP: * Please continue to monitor the patient's mood and ADHD symptoms. * Please consider a referral to an occupational therapist for further support. Recommendations for patient: 1. Continue taking Sertraline and Methylphenidate as prescribed. 2. Continue attending therapy sessions with Dr. Jones. 3. Implement strategies for managing ADHD symptoms, such as using a planner and breaking down tasks. Please contact reception@pandionhealth.com.au if you require any clarification or assistance.