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MEDICATION MANAGEMENT VISIT
CC/Reason for today's visit: 6th monthly Follow Up Visit for medication
management related to his bipolar, ADHD and anxiety.
1. Adderall 20 mg 3x day. 2. Lamictal 200 mg in the morning and 100 mg at night 3. Clonazepam 1 mg 3x day 4. Ambien 10 mg at night He is c/o a little bit more anxiety and wants to get off clonazepam and switch to Xanax because that was more helpful in the past. He also stopped taking Adderall and was hoping to maybe use a once a day version of that, specifically the Vyvanse so he does not need to remember multiple dosing. Apart from that, his moods have been stable on the Lamictal. No depression. No problem with depressed mood, appetite, energy or motivation. Also no episodes of racing thoughts, rapid speech or decreased need for sleep. Denies any suicidal ideation or psychotic symptoms. Assessment:
1. Medication management
2. Bipolar I disorder, most recent episode depression, stable
2. ADHD, combined type, symptomatic off the Adderall
3. Generalized anxiety disorder, still symptomatic
Plan:
1. Stop clonazepam
2. Begin Xanax 1 mg 3x a day 3. Stop Adderall 4. Begin Vyvanse 40 mg daily 5. FU with me in one month and as needed.
Clinical Progress Toward Goals: We continue to successfully work toward control
Patient Progress Toward Goals: "slow progress, it might be better"
MEDICATION MANAGEMENT VISIT
CC/Reason for today's visit: 6th monthly Follow Up Visit for medication
management related to his bipolar, ADHD and anxiety.
3. Adderall 20 mg 3x day. 4. Lamictal 200 mg in the morning and 100 mg at night 3. Clonazepam 1 mg 3x day 4. Ambien 10 mg at night He is c/o a little bit more anxiety and wants to get off clonazepam and switch to Xanax because that was more helpful in the past. He also stopped taking Adderall and was hoping to maybe use a once a day version of that, specifically the Vyvanse so he does not need to remember multiple dosing. Apart from that, his moods have been stable on the Lamictal. No depression. No problem with depressed mood, appetite, energy or motivation. Also no episodes of racing thoughts, rapid speech or decreased need for sleep. Denies any suicidal ideation or psychotic symptoms. 10 of 15 minutes spent counseling patient regarding wish medication
modifications and possible outcomes. He agrees to journal results and
comments.
Assessment:
2. Bipolar I disorder, most recent episode depression, stable 2. ADHD, combined type, symptomatic off the Adderall 3. Generalized anxiety disorder, still symptomatic Plan:
1. Stop clonazepam
2. Begin Xanax 1 mg 3x a day 3. Stop Adderall 4. Begin Vyvanse 40 mg daily 5. FU with me in one month and as needed. Clinical Progress Toward Goals: We continue to successfully work toward control
Patient Progress Toward Goals: "slow progress, it might be better"
MEDICATION MANAGEMENT VISIT
CC/Reason for today's visit: 6th monthly Follow Up Visit for medication
management related to his bipolar, ADHD and anxiety.
He is c/o a little bit [severity- HPI qualifier] more anxiety and wants to get off clonazepam [modifying factor- HPI qualifier] and switch to Xanax because that was more helpful in the past. He also stopped taking Adderall and was hoping to maybe use a once a day version of that, specifically the Vyvanse so he does not need to remember multiple dosing. Apart from that, his moods have been stable [ROS of psych system] on the Lamictal. No depression. No problem with depressed mood, appetite, energy or motivation [ROS constitution]. Also no episodes of racing thoughts, rapid speech or decreased need for sleep. Denies any suicidal ideation or psychotic symptoms [exam]. Assessment:
1. Medication management
2. Bipolar I disorder, most recent episode depression, stable
2. ADHD, combined type, symptomatic off the Adderall
3. Generalized anxiety disorder, still symptomatic
Plan:
1. Stop clonazepam
2. Begin Xanax 1 mg 3x a day
3. Stop Adderall
4. Begin Vyvanse 40 mg daily
5. FU with me in one month and as needed.

Clinical Progress Toward Goals: We continue to successfully work toward control
Patient Progress Toward Goals: "slow progress, it might be better"
2nd Scheduled Follow up Visit for Marta 9/10/2012
Follow up for this 54 year old evaluated on 8/3/2012 for diagnoses of
1. Major Depressive Disorder, Recurrent, Moderate
Medications prescribed 8/3/2012 1. bupropion SR 150 mg q am (DPN/ADHD) 2. clonidine, 0.1 mg, one to two bedtime prn anxiety/insomnia 3. continue sertraline 100mg daily for DPN/anxiety Your clinician will document significant history and exam in record. The final hx, ex and MDM will influence code selection unless time is appropriately documented. (History) HPI 8 qualifiers, ROS, 10 systems, any medical or social history (Exam) Psychiatric exam elements or physical exam of any body systems (MDM) Assessment and Plan The majority of this __________ minute visit was spent counseling regarding.

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