Medication Management Note

Subjective:
Date of Consultation:
2025-07-18

Time:
14:17 - 14:47

Mode:
Video call

TELEHEALTH CONSENT:
☐ Patient verbally consented to telehealth consultation 
☐ Patient identity verified via visual confirmation and verbal confirmation of personal details

All assessments and observations were conducted remotely via secure video platform. Jamie self-reported symptoms and responded to structured clinical interview. No direct physical examination was performed. Observations regarding Jamie's appearance, behavior, and affect were made via video. No home monitoring devices or third-party information were utilized during this encounter.

Chief Complaint:
Follow-up for attention deficit hyperactivity disorder with ongoing difficulty maintaining focus and attention at work, particularly in the afternoons, despite current medication regimen. Jamie also reports intermittent sleep disturbances and low energy during the day. No change in appetite and no depressive symptoms are noted.

Medication Efficacy:
- Patient reports partial improvement in symptoms of attention-deficit/hyperactivity disorder, with increased ability to complete chores and maintain motivation at home. 
- Jamie continues to experience significant distractibility and difficulty sustaining attention at work, particularly in the afternoon, despite current pharmacotherapy.

Side Effects:
- Patient endorses mild side effects, specifically occasional grogginess upon awakening when hydroxyzine is used for sleep. 
- Jamie does not report any other adverse effects such as sedation, weight gain, or other medication-related complaints. The side effect does not significantly impact willingness to continue treatment.

Compliance / Adherence:
- Medication taken as prescribed? Yes
- If no, reason for non-adherence: 
- Missed doses: 

Other Updates:
- Jamie reports recent psychosocial changes, including starting a new, detail-oriented job two months ago and moving into a larger apartment within the past year. These environmental changes have contributed to increased responsibilities and may be impacting symptom management.

Objective:
Mental Status Examination:
 Jamie appears well-groomed and cooperative via video. No abnormal movements or behaviors observed.
 Speech is spontaneous, coherent, and goal-directed. Thought process is logical and organized.
 Mood is described as good. Affect is congruent with stated mood and appropriate to context.
 Insight and judgment are intact.
 No.

Assessment:
Attention-deficit/hyperactivity disorder (F90.0). Jamie is experiencing partial improvement on current medication regimen, with persistent symptoms of distractibility and decreased focus in occupational settings. No evidence of depressive symptoms or appetite changes. Jamie demonstrates good adherence and tolerability, with only mild, intermittent side effects.

Changes Today:
- Increased Vyvanse from 60 mg to 80 mg daily due to persistent attention and focus difficulties at work, particularly in the afternoon.

Plan:
- Increase Vyvanse to 80 mg daily to address attention and focus deficits impacting occupational functioning. Monitor for side effects, including grogginess or other adverse reactions.
- Confirm no new medications prescribed by other providers and no over-the-counter medications taken.
- Schedule follow-up in 4 to 5 weeks to evaluate response to dosage adjustment and assess symptom progression.
- Consider further dosage adjustments or augmentation strategies if afternoon symptoms persist at the next visit.