Objective:

1. General Appearance: Not mentioned in the transcript, no obvious concerns noted.
2. Behavior: Cooperative, engaged in the conversation.
3. Speech: Clear, understandable.
4. Language: Adequate comprehension and expression.
5. Thought Form: Logical and coherent.
6. Thought Content: No evidence of delusions or thought disorder.
7. The Patient’s Description of Their Emotional State: Mostly stable, occasional anxiety
8. Signs of psychosis: None reported.
9. Suicidality: Not mentioned in the transcript, not inferred.
10. Homicidality: Not mentioned in the transcript, not inferred.
11. Capacity to Participate in the Medical Assessment: Able to participate effectively in a telehealth appointment
12. Judgment: Appears to be intact.
13. Insight into the illness: Shows understanding of her condition and considers various treatment options.
14. General Cognitive Function: Intact, able to follow the conversation and understand treatment options.
15. Proverb Interpretation: Not assessed during the appointment.
16. WORLD or Mental Calculations: Not assessed during the appointment.
17. Ability to Read and Explain a Narrative Paragraph: Not assessed during the appointment.
18. Ability to Follow Instructions: Demonstrated by successfully participating in the telehealth appointment.

Therapy:

Above and beyond the medical decision-making for this visit, we discussed the patient’s ongoing anxiety and stress related to limited social activities and difficulty

managing autonomic dysfunction. We explored the benefits of engaging in more social activities and various potential treatment options to address the patient’s mental health concerns

The goal of psychotherapy is to help the patient better manage anxiety and stress, while providing coping strategies to deal with symptoms of autonomic dysfunction and any related stressors

The patient is making progress in considering various treatment options, engaging in social activities, and benefiting from support from her son.

In the next visit, we will review the patient’s progress and continue to discuss potential treatment options, as well as address any ongoing stressors or concerns

Assessment:

1. Most likely DSM-5 diagnosis at this time: Generalized Anxiety Disorder.
2. Most likely stressful situations that might have a negative impact on mental health: Limited social activities and difficulty managing anxiety and autonomic dysfunction.
3. Most likely pre-existing risk for the most likely mental illness(es) evident at this time: Not mentioned in the transcript, potential genetic predisposition to anxiety disorders.
4. Most likely special reason(s) for the current episode of illness: Balancing blood pressure medications, managing autonomic dysfunction symptoms, and ongoing stressors.
5. Factors that are delaying recovery from illness: Ongoing experimentation with medications, co-morbid physical health problems, lack of consistent treatment or therapy for anxiety.
6. Factors that protect the patient from mental illness: Support from the daughter, engaging in church activities, and considering various treatment options.

Plan:

1. Medication Suggestions: Continue hydroxyzine as needed for anxiety, and explore norepinephrine-based medications and other options in future appointments.
2. Labs and other Investigations: None mentioned during the appointment.
3. Talk Therapy or Counselling: Psychotherapy to address anxiety and potential coping strategies.
4. Lifestyle and Stress Management: Engage in more social activities (e.g., church group exercise classes), maintain a routine.
5. Health Education: Provide information on managing anxiety, autonomic dysfunction, and blood pressure.
6. Emergency and Safety Planning: If a mental health emergency arises, the patient should call 911 or visit a local emergency or urgent care center.
7. Plans for Follow-Up: Schedule a follow-up appointment in two months.
8. Other medical counseling: Work with primary care physician, neurologist, or a compounding pharmacist to optimize blood pressure medication regimen.

Billing:

CPT billing codes for this appointment:

• 99213: 15-29 minutes of E/M outpatient visit (evaluation and management) for an established patient.
• 90836: Psychotherapy add-on code (30-37 minutes) in conjunction with E/M appointment.

Reasoning: The appointment included both evaluation and management of the patient’s mental health concerns, as well as psychotherapy discussing stress and anxiety management.

To maximize billing reimbursement, the appointment could have included a more detailed assessment or review of systems, addressing more areas related to the patient’s anxiety and autonomic dysfunction. or potentially recommending more clinical tests or labs.

After Visit Summary:

During our appointment, we discussed your ongoing anxiety and stress related to limited social activities and difficulty managing your autonomic dysfunction. We explored potential treatment options, including norepinephrine-based medications, and several suggestions to improve your overall mental and physical well-being.

It is important to be aware of any side effects or risk factors associated with your current medications:

Hydroxyzine: Common side effects can include drowsiness, dizziness, dry mouth, and headache. More severe side effects can include changes in mood, confusion, difficulty breathing, and memory problems. If you experience any of these severe side effects, contacting your healthcare provider promptly is important.

Please continue monitoring your blood pressure and work with your primary care physician, neurologist, or a compounding pharmacist to optimize your medication regimen. In addition, focusing on activities and lifestyle changes that can help manage stress and anxiety will benefit your overall mental health.

If you have any concerns or experience significant changes in your mental or physical health, please do not hesitate to contact our office or seek medical attention as necessary.

Other:

Tasks to complete after the appointment:

1. Add the patient’s appointment notes to their medical chart.
2. Research compounding pharmacies in the patient’s area to provide further recommendations.
3. Follow up on the patient’s progress regarding church activities, medication use, and blood pressure management.
4. Monitor for any urgent issues that may arise before the next appointment.

Topics to cover at the next appointment:

1. Update on the patient’s mental health status and any changes in anxiety or autonomic dysfunction symptoms.
2. Progress on social activities, including church group exercise classes.
3. Review any adjustments made to the patient’s blood pressure medication regimen.
4. Discuss any new medications or treatment options considered in the interim.