Complete patient context
Review patient history with AI-summarized Patient Recaps
Prior notes, assessments, and medication history pulled directly from your EHR
Structured chronological summary of the patient’s clinical journey
Reduces chart review time by up to 90%
Complete Clinical Picture
Automatically structures mental status exams and embeds psychometric scores into the note.
Captures appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, judgment, and impulse control
Auto-inserts PHQ-9, GAD-7, MMPI, and other scores with interpretive summaries
Generates structured summaries of technical test results
Provider-Personalized Notes
Generate documentation that matches your preferred style.
Custom templates for conditions like ADHD, Anxiety, Dementia etc.
Therapy-specific templates for CBT, DBT, and psychodynamic therapy
Documents differential diagnoses alongside the assessment
Adjustable sensitivity captures more or less subjective and psychosocial detail
Documents differential diagnoses alongside the assessment
Complete Treatment Timeline
Logs psychiatric medications and changes across the full treatment timeline.
Current and discontinued medications with dosage changes
Adherence issues and side effects tracked over time
Reduces chart review time by up to 90%
MDM-Backed Coding
Generate accurate, evidence-backed billing and coding.
ICD-10, CPT, and E/M coding with MDM rationale
Captures modifiers, HCC, and risk-factor flagging automatically
Reduce undercoding with evidence-backed coding
When we looked for AI scribe vendors we went through a tedious process to find the right fit and we've found that in Marvix AI. Their software is customizable, integratable with EMR, specialist-friendly and is incredibly user friendly. They're responsive and willing to meet you where you are in today's ever changing AI landscape.
AM
Amanda McFayden
Director of Clinical Operations, DENT Neurologic Institute
Absolutely transformative! Marvix AI has literally changed my life by giving me back my most precious resource—time. I no longer spend weekends and evenings painstakingly finishing notes or writing long letters. With Marvix AI, I have my own personal scribe that seems to know me better than I know myself.
MC
Dr. Madeline Chadehumbe
CMO, Neurabilities
Marvix AI is amazing. It cuts the physician's cognitive effort by 50%. It captures details necessary for billing and documentation. I highly recommend it to all providers.
MQ
Dr. Mohammad Qasaymeh
Director of Pediatrics, DENT Neurologic Institute
Marvix AI has changed my work-life balance significantly! It's the single best advancement in charting — EVER!
TP
Tammy Pesaresi, AGPCNP-C
DENT Neurologic Institute
Pre-Visit Summaries
Complete Patient Context
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Review patient history with AI-summarized Patient Recaps
Prior notes, assessments, and medication history pulled directly from your EHR
Structured chronological summary of the patient’s clinical journey
Reduces chart review time by up to 90%
Assessments & Scores
Complete Clinical Picture
Automatically structures mental status exams and embeds psychometric scores into the note.
Captures appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, judgment, and impulse control
Auto-inserts PHQ-9, GAD-7, MMPI, and other scores with interpretive summaries
Generates structured summaries of technical test results
Custom Clinical Notes
Provider-Personalized Notes
Generate documentation that matches your preferred style.
Custom templates for conditions like ADHD, Anxiety, Dementia etc.
Therapy-specific templates for CBT, DBT, and psychodynamic therapy
Documents differential diagnoses alongside the assessment
Adjustable sensitivity captures more or less subjective and psychosocial detail
Builds chronological summaries of mood episodes and behavioral patterns across visits
Medication Regimen Tracking
Complete Treatment Timeline
Logs psychiatric medications and changes across the full treatment timeline.
Current and discontinued medications with dosage changes
Adherence issues and side effects tracked over time
Carries forward regimen history into every follow-up note
MDM-Backed Coding
Generate accurate, evidence-backed billing and coding.
ICD-10, CPT, and E/M coding with MDM rationale
Captures modifiers, HCC, and risk-factor flagging automatically
Reduce undercoding with evidence-backed coding
1
Before the Visit
Complete Patient Context
Before you walk into the room, Marvix AI has already reviewed the chart for you.
AI-generated Patient Recap summaries
Retrieves prior notes, assessments, and medications from your EHR
Appointment schedule synced from your EHR
The whole care team contributes to one note
Active problems and HCC recapture
Care-gap and MIPS/HEDIS alerts
Coverage and eligibility check
2
During the Visit
Complete Consult Intelligence
Ambient capture of the full psychiatric encounter, merged into one structured note as you speak.
Ambient note generation as you speak
Captures mental status exam findings
Captures every clinical detail accurately
Captures full detail across 90+ minute sessions
Custom templates per condition and therapy type
Documents differential diagnoses
Macros insert risk-assessment and safety-plan language
Adjusts note sensitivity to capture more or less detail
Real-time documentation nudges and missing-detail alerts
3
After the Visit
Insurance-Ready Documentation
Clinical notes, coding, and patient documents are generated and pushed back to your EHR in one click.
Complete clinical notes in your style
ICD-10, CPT, and E/M coding with MDM rationale, modifiers, HCC, and risk flagging
Medical-necessity and LCC language for payers
Carries forward histories, assessments, and medication regimen from past visits
One-click sync into EHR sections, including order sets, with audit-ready trail
AVS, referral letters and patient instructions
Marvix AI works alongside your existing EHR—pulling the right patient data before every visit and pushing structured documentation back into the correct sections automatically.
No manual copy-paste
No new workflows to learn
Supports FHIR, HL7, and API integrations
FROM YOUR EHR
Automatically Available
Appointments & Schedule
Prior Notes
Labs & Imaging
Medications
Intake Forms
Scanned Documents
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BACK TO YOUR EHR
Automatically Synced
Clinical Notes
ICD-10 & E/M Coding
Referral Letters
After Visit Summary (AVS)
Patient Instructions
Section-Mapped Documentation
Two-Way Sync
Real-Time Updates
No Integration Fee*
HIPAA Compliant
No middleware required
Connects with your EHR
Don't see your EHR? We can build a custom integration for your practice. Talk to us
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Don't see your EHR? We can build a custom integration for your practice. Talk to us.
Every Marvix AI note ties documentation to the codes it supports. The level you bill is the level you can defend, and the proof is already in the note.
E/M level justified
MDM complexity, total time, and counseling are captured directly in the note as you document the visit.
ICD-10 to the right specificity
Diagnosis type, severity, and episode specifiers are coded to the specificity payers require.
CPT codes captured
Psychotherapy add-on codes are pulled from session time and linked to the visit automatically.
Audit-ready trail
Every code links back to the exact line in the note that supports it, so the proof is ready if a claim is reviewed.
HCC recapture & modifiers
Serious mental illness and chronic conditions are recaptured for accurate HCC risk scores, with modifiers applied to reflect the true complexity of the visit.
$262B B
in claims denied annually falls into the gap between what's written and what payers require. (CAQH)
Coding
Audit-ready
SUPPORTED BY
Detailed interval history documenting mood, symptom severity, and treatment response
Structured mental status exam findings
Moderate-complexity medical decision-making
ICD-10
F33.1 · Major depressive disorder, recurrent, moderate
E/M
99214 · Established patient, moderate complexity
CPT
90836 · Psychotherapy add-on, 45 minutes
HCC
HCC 59 · Major depressive/bipolar disorder (recaptured)
Modifiers
Separate E/M service on the same day as psychotherapy
Pick a scenario to preview the structure Marvix AI generates. It adapts to your own writing style once it learns from your notes.
Chief Complaint
Worsening depression over four months following her father's death, with low motivation, oversleeping, and passive thoughts of death.
History of Present Illness (HPI)
Sabrina Bergling is a 38-year-old female with recurrent major depressive disorder, with episodes in 2016 and 2020, who presents for an initial psychiatric evaluation of worsening depression over the past four months.
Since her father died in May 2026, she reports low mood most days, loss of interest in painting and her children's activities, sleeping 10 to 11 hours, and a 6 kg weight gain. She feels "heavy" and crushed by small criticisms at work. She has passive thoughts that her family would be better off without her, with no intent or plan. Her evening wine intake has increased. She states, "I know what depression feels like, and this is the deepest it's ever been."
Psychotherapy Summary
We explored her grief over her father's death from pancreatic cancer in May 2026 and her guilt about not visiting more often during his final months. She described a recurring thought that she "fails everyone she loves," which intensifies after minor feedback at work. We identified this as a self-critical pattern consistent with her prior episodes.
We reviewed how oversleeping, withdrawal from painting, and evening wine use are maintaining her low mood. We introduced behavioral activation and planned two small, valued activities for the coming week: painting for 20 minutes on Saturday morning and walking her children to school twice. She was tearful when discussing her father and visibly calmer after completing her safety plan, stating, "Having a plan written down helps me feel less trapped."
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
2016: First major depressive episode with postpartum onset after the birth of her first child. Treated with sertraline and supportive counseling, with full remission by 2017.
2020: Second major depressive episode after losing her job during the pandemic. Treated with escitalopram and 12 sessions of CBT, with partial response and remission by mid-2021.
2023: Tapered off escitalopram with her primary care physician due to sexual side effects and weight gain. Remained well until 2026.
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Sertraline (2016 to 2017): Titrated to 100 mg daily. Full response. Mild sexual side effects. Discontinued after 12 months of remission.
Escitalopram (2020 to 2023): Titrated to 20 mg daily. Partial response. Discontinued for sexual dysfunction and 5 kg weight gain.
Trazodone (2020): 50 mg at bedtime for sleep. Discontinued after two weeks for morning grogginess.
Family History
Family Details (current)
Married for 12 years and lives with her husband and two children, ages 10 and 7. Her husband is supportive, attended the first half of today's visit, and reports she has "stopped being herself" since the summer. Her mother lives 20 minutes away and has been grieving as well.
Sexual Activity
Sexually active with her husband. Reports decreased libido over four months. Sexual side effects with both prior SSRIs were a main reason for stopping treatment.
Social History
Education level: Bachelor's degree in graphic design.
Religious or Spiritual Involvement: Raised Methodist. Attends church occasionally and finds it comforting.
Employment: Works full time as a senior graphic designer. Missed four days of work in the past month and received critical feedback on a recent project.
Smoking Status: Never smoker. No vaping.
Alcohol use: Increased from one glass of wine on weekends to two to three glasses most evenings since June 2026.
Caffeine use: Two cups of coffee each morning.
Drug use: Denies cannabis or other drug use.
Abuse History: Denies history of physical, sexual, or emotional abuse.
Firearms: Husband owns two hunting rifles stored in a locked safe.
Substance Abuse History
Substance of choice: Alcohol.
History: No prior concerns before 2026. No withdrawal symptoms, blackouts, or legal problems. AUDIT-C score of 5, consistent with hazardous use. Family history of alcohol use disorder increases risk.
Psychometric Assessment
PHQ-9: 19, moderately severe depression. Item 9 positive for thoughts that she would be better off dead on several days.
GAD-7: 11, moderate anxiety.
Mood Disorder Questionnaire: 3 of 13, negative screen for bipolar spectrum disorder.
AUDIT-C: 5, hazardous alcohol use.
Columbia Suicide Severity Rating Scale Screener: Positive for wish to be dead. Negative for active ideation, method, intent, plan, or past behavior.
MMPI-2 (completed 09/2026):
Validity Scales: L 48, F 62, K 45. Valid profile without over-reporting or defensiveness.
Scale 2 (Depression): T-score 78, clinically elevated. Reflects pervasive sadness, low energy, hopelessness, and loss of interest.
Scale 7 (Psychasthenia): T-score 71, clinically elevated. Reflects worry, self-doubt, rumination, and self-critical thinking.
Scale 8 (Schizophrenia): T-score 58, within normal limits. No evidence of thought disorder.
Scale 9 (Hypomania): T-score 42, low. No evidence of hypomanic energy or activation.
Interpretive Summary: Internalizing profile with prominent depression and anxious rumination, consistent with a self-critical cognitive style. No indication of psychosis or bipolar-spectrum features.
Medical Workup
Primary Care Labs (08/2026): TSH 2.3 uIU/mL. CBC and CMP within normal limits. Vitamin B12 410 pg/mL. 25-hydroxyvitamin D 18 ng/mL (low). Urine pregnancy test negative.
Mental Status Exam
Appearance: Casually dressed, adequately groomed. Appears tired.
Behavior: Cooperative with reduced eye contact. Mild psychomotor slowing.
Speech: Slowed rate, soft volume, with long pauses before answering.
Mood: "Empty and heavy."
Affect: Constricted, dysphoric, and tearful when discussing her father. Brightens briefly when discussing her children.
Thought Process: Linear and goal-directed.
Thought Content: Themes of guilt, worthlessness, and failure. Passive death wish without intent or plan. No homicidal ideation. No delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Attention reduced on serial sevens. Memory grossly intact.
Insight: Good. Recognizes this as a depressive episode.
Judgment: Fair, given increased alcohol use to manage mood.
Impulse Control: Good.
Differential Diagnosis
Major depressive disorder, recurrent, severe, with atypical features and anxious distress: Most consistent with three discrete episodes, hypersomnia, weight gain, leaden fatigue, and rejection sensitivity.
Bipolar II disorder: Considered given her brother's bipolar I disorder. No history of hypomania, MDQ negative, and MMPI-2 Scale 9 low.
Prolonged grief disorder: Grief is a clear trigger, but symptoms extend well beyond grief and have lasted four months.
Alcohol-induced depressive disorder: Less likely, as depression preceded the increase in alcohol use and her prior episodes occurred without alcohol.
Depression due to a medical condition: Thyroid function and B12 are normal.
Risk Assessment
Risk Factors: Current severe depressive episode, passive death wish, recent bereavement, increased alcohol use, firearms in the home, and family history of mood disorders.
Protective Factors: Strong connection to her children and husband, no history of suicide attempts, good insight, engagement in treatment, and religious involvement.
Assessment: Low to moderate acute risk. Outpatient care is appropriate. Safety plan completed today with warning signs, coping strategies, contacts, and 988 Suicide and Crisis Lifeline information. Her husband agreed to change the safe combination and move ammunition to her brother-in-law's home.
Plan
Sabrina Bergling is a 38-year-old female with recurrent major depressive disorder presenting with her third and most severe episode, triggered by her father's death and complicated by increased alcohol use and passive thoughts of death.
1. Major Depressive Disorder, Recurrent, Severe, Without Psychotic Features, with Atypical Features and Anxious Distress
She meets criteria for a severe recurrent episode with PHQ-9 of 19 and MMPI-2 Scale 2 at a T-score of 78. Prior SSRIs worked but were stopped for sexual side effects and weight gain. Vortioxetine carries lower rates of both and may help her concentration.
2. Hazardous Alcohol Use
Her alcohol intake has tripled since June 2026 and is worsening her mood and sleep.
3. Suicide Risk
Passive death wish without intent or plan, with firearms secured during today's visit.
4. Bereavement
Her grief over her father's death is a central theme and an ongoing trigger.
5. Monitoring for Bipolar Spectrum Symptoms
Her brother's bipolar I disorder raises her risk of antidepressant-related activation.
6. Vitamin D Deficiency
Vitamin D level of 18 ng/mL may be adding to fatigue.
7. Follow Up
Chief Complaint
Follow-up for generalized anxiety and panic disorder, with medication management and CBT session 6.
History of Present Illness (HPI)
Addison Wentz is a 29-year-old female with generalized anxiety disorder and panic disorder who presents for medication management and her sixth CBT session in the current treatment course.
She reports two panic attacks in the past month, down from six in June, both while driving on the interstate. Worry about her new team lead role keeps her awake about an hour most nights. She used lorazepam three times this month. She completed her exposure goal of driving two exits on the interstate with her partner. She denies depressed mood, suicidal thoughts, or alcohol use to cope. She states, "My heart still races on the ramp, but I didn't turn around this time."
Psychotherapy Summary
We reviewed her exposure homework. She drove two exits on the interstate with her partner on three occasions. Peak distress fell from 80 to 55 on a 0 to 100 scale by the third drive, and she did not exit early or use lorazepam during any of them.
We used cognitive restructuring on her belief that a racing heart means she will lose control of the car. She identified evidence against this belief, including more than 40 panic attacks without losing control and a normal cardiac workup in 2022. She reframed the thought as "My body is having an alarm reaction, and I can keep driving through it."
We completed interoceptive exposure with 60 seconds of breathing through a straw and 30 seconds of spinning in a chair. Distress ratings dropped from 70 to 40 across three trials. We discussed how lorazepam use before drives acts as a safety behavior that limits new learning.
For worry about work, we introduced a 20-minute worry postponement period at 6:00 PM. She engaged well, appeared more confident by the end of the session, and said, "It helps to see that my body is the problem, not the road."
Exposure Hierarchy
Drive on side streets alone: Distress 15, mastered
Drive on a highway frontage road alone: Distress 30, mastered
Drive two interstate exits with partner: Distress 55, current step
Drive two interstate exits alone with partner following: Distress 70, next step
Drive four interstate exits alone: Distress 85
Drive on the interstate during rush hour alone: Distress 95
Psychiatric History
2011: Excessive worry about school and family with frequent stomachaches. Met with the school counselor.
2016: Diagnosed with generalized anxiety disorder by college student health. Completed six counseling sessions.
03/2022: First panic attack while driving on the interstate. Emergency department visit with normal ECG, troponin, and TSH. A second emergency visit followed in 06/2022 with the same results. Began avoiding highways.
01/2023: Began psychiatric care. Diagnosed with panic disorder and generalized anxiety disorder. Started sertraline.
2024: Completed 12 sessions of CBT for panic disorder. Panic attacks decreased from eight to one per month, and she resumed limited highway driving.
2025: Prescribed lorazepam at urgent care after a panic attack during a flight. Used once or twice monthly.
05/2026: Promoted to team lead. Worry, insomnia, and panic attacks increased to six per month, and highway avoidance returned.
08/2026: Resumed weekly CBT with exposure-based treatment.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Sertraline (2023 to present): Started at 50 mg, increased to 100 mg in 2023 and 150 mg in 2024. Good response with mild early nausea.
Lorazepam (2025 to present): 0.5 mg as needed, prescribed by urgent care. Used one to three times monthly.
Hydroxyzine (2023): 25 mg as needed. Effective but caused next-day drowsiness at bedtime doses.
Current Medications
Sertraline 150 mg daily
Lorazepam 0.5 mg as needed for panic
Albuterol HFA 90 mcg as needed for wheezing
Levonorgestrel intrauterine device
Family History
Social History
Education level: Bachelor's degree in accounting.
Religious or Spiritual Involvement: Not religious. Practices yoga weekly.
Employment: Works as a team lead at an accounting firm since 05/2026. Hybrid schedule with a 35-minute commute that includes the interstate.
Living Situation: Lives with her partner of four years.
Smoking Status: Never smoker. No vaping.
Alcohol use: One to two drinks on weekends.
Caffeine use: One cup of coffee in the morning, reduced from three in 2024.
Drug use: Denies cannabis or other drug use.
Abuse History: Denies history of abuse.
Substance Abuse History
Substance of choice: None.
History: No history of substance use disorder. State prescription monitoring program reviewed today, showing lorazepam from a single prescriber with no early refills.
Psychometric Scores
GAD-7: 06/2026: 16. 08/2026: 14. 09/2026: 13. Today: 12.
Panic Disorder Severity Scale: 06/2026: 15. 08/2026: 13. 09/2026: 11. Today: 9.
Panic Attacks per Month: 06/2026: 6. 08/2026: 4. 09/2026: 3. Today: 2.
PHQ-9: 06/2026: 7. Today: 5.
Insomnia Severity Index: 06/2026: 16. Today: 14.
Columbia Suicide Severity Rating Scale Screener: Negative.
Medical Workup
Emergency Department Evaluations (03/2022 and 06/2022): ECG with normal sinus rhythm. Troponin negative. TSH 1.8 uIU/mL.
Echocardiogram (2022): Normal structure and function.
Primary Care Labs (2026): TSH 2.0 uIU/mL. CBC normal.
Mental Status Exam
Appearance: Well groomed and dressed in business casual attire.
Behavior: Cooperative with good eye contact. Mild restlessness early in the session that settled by the end.
Speech: Normal rate and volume, slightly rapid when describing driving.
Mood: "Anxious, but better than last month."
Affect: Anxious, congruent with content, and brighter when reviewing progress.
Thought Process: Linear and goal-directed.
Thought Content: Worry centered on work performance and fear of panic while driving. No suicidal or homicidal ideation. No obsessions or delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Attention and memory intact.
Insight: Good. Understands the panic cycle and the role of avoidance.
Judgment: Good.
Impulse Control: Good.
Risk Assessment
Risk Factors: Anxiety disorders and increased work stress.
Protective Factors: Supportive partner, stable employment, strong engagement in therapy, no suicidal ideation, and no substance misuse.
Assessment: Low acute risk. Outpatient care remains appropriate.
Plan
Addison Wentz is a 29-year-old female with generalized anxiety disorder and panic disorder with driving-related avoidance, showing steady improvement in panic frequency and severity with residual worry and insomnia.
1. Generalized Anxiety Disorder
GAD-7 has improved from 16 to 12 but remains in the moderate range, with work-related worry driving insomnia. She has tolerated sertraline 150 mg well for two years.
2. Panic Disorder with Driving-Related Avoidance
Panic attacks have decreased from six to two per month, and Panic Disorder Severity Scale has improved from 15 to 9. She is progressing through her exposure hierarchy without escape behavior.
3. As-Needed Benzodiazepine Use
Lorazepam before drives is acting as a safety behavior and may slow exposure progress. Hydroxyzine previously helped at daytime doses.
4. Insomnia
Sleep onset is delayed by about an hour from work-related worry.
5. Mild Intermittent Asthma
Beta-blockers for anxiety are avoided given her asthma.
6. Follow Up
Time Documentation
Psychotherapy Start Time: 2:05 PM
Psychotherapy Stop Time: 2:50 PM
Total Psychotherapy Time: 45 minutes, separate from time spent on medication management.
Billing Considerations
Established patient E/M visit at moderate complexity for prescription drug management, with a separately documented 45-minute psychotherapy add-on and diagnosis linkage to generalized anxiety disorder and panic disorder.
Chief Complaint
Adult ADHD evaluation for lifelong inattention, disorganization, and impulsivity affecting work, driving, and relationships.
History of Present Illness (HPI)
Andy Comstock is a 41-year-old male who presents for an adult ADHD evaluation after his 9-year-old son was diagnosed with ADHD in spring 2026 and he recognized similar patterns in himself.
He describes lifelong difficulty sustaining attention in meetings, losing track of tasks halfway through, and missing deadlines, which led to a performance improvement plan at work in August. His wife reports he interrupts conversations and forgets commitments. He has had three speeding tickets in five years. He denies depressed mood, current substance use, or suicidal thoughts. He states, "I've spent my whole life thinking I was just lazy, and watching my son made me wonder."
Primary Concerns and Reason for Evaluation
Diagnostic clarification of adult ADHD and treatment options, prompted by worsening work performance, his son's diagnosis, and strain in his marriage.
Developmental and Childhood History
Born full term without complications. Met developmental milestones on time. No head injuries, seizures, or serious childhood illnesses. His mother describes him as "always on the go," climbing furniture, and unable to sit through family meals. Teachers frequently moved his seat for talking out of turn. He was never evaluated for ADHD.
School and Learning
Elementary report cards from 1992 to 1996 include comments such as "bright but easily distracted" and "rarely finishes classwork." Attended summer school for math in 7th grade. Graduated high school with a 2.6 GPA. Left a 4-year college after three semesters in 2004 due to missed assignments. Completed an associate degree in logistics online in 2010, which took four years.
Occupational History
Has held six jobs over 15 years, most ending due to missed deadlines or boredom. Has worked as a logistics coordinator at his current company for four years. Placed on a performance improvement plan in 08/2026 for late reports and errors in shipment schedules.
Social and Relationship Functioning
Married for 11 years with two children, ages 9 and 6. His wife manages household finances after several late bill payments. Couples counseling in 2024 focused on forgotten commitments and interrupting. Has close friendships but often arrives late to plans.
Collateral Information
Wife (interviewed in person): Reports he loses keys and his phone daily, starts home projects without finishing them, and interrupts others. Describes him as "loving but scattered." Confirms loud snoring and pauses in his breathing at night.
Mother (interviewed by phone): Confirms hyperactivity, impulsivity, and inattention from early elementary school, consistent with his report cards.
Records Reviewed: Elementary report cards from 1992 to 1996, his son's ADHD evaluation from 05/2026, and driving record showing three speeding tickets and two minor rear-end collisions in 2019 and 2023.
Rating Scales and Structured Interview
Adult ADHD Self-Report Scale (ASRS v1.1) Part A: 5 of 6, positive screen.
Wender Utah Rating Scale: 58, above the cutoff of 46, supporting childhood ADHD symptoms.
Conners' Adult ADHD Rating Scales, Self-Report: ADHD Index T-score 72. DSM Inattentive Symptoms T-score 76. DSM Hyperactive-Impulsive Symptoms T-score 69.
Conners' Adult ADHD Rating Scales, Observer (Wife): ADHD Index T-score 75. DSM Inattentive Symptoms T-score 78. DSM Hyperactive-Impulsive Symptoms T-score 71.
Interpretive Summary: Self and observer ratings are consistent and clinically elevated, with inattention most prominent. Agreement between his report and his wife's ratings supports validity.
Diagnostic Interview for ADHD in Adults (DIVA-5):
Inattention, Childhood: 7 of 9 criteria
Inattention, Adulthood: 8 of 9 criteria
Hyperactivity-Impulsivity, Childhood: 8 of 9 criteria
Hyperactivity-Impulsivity, Adulthood: 6 of 9 criteria
Impairment: Present at work, in education, in relationships, in finances, and in driving, in both childhood and adulthood.
Screening for Comorbid Conditions
PHQ-9: 6, mild depressive symptoms related to work stress.
GAD-7: 8, mild anxiety centered on job performance.
Mood Disorder Questionnaire: 2 of 13, negative.
AUDIT-C: 2.
STOP-BANG: 5, high risk for obstructive sleep apnea.
Epworth Sleepiness Scale: 11, mild excessive daytime sleepiness.
Columbia Suicide Severity Rating Scale Screener: Negative.
Psychiatric History
2019: Treated by his primary care physician with escitalopram 10 mg for anxiety. Minimal benefit after 8 months. Discontinued.
2024: Completed 10 sessions of couples counseling.
No psychiatric hospitalizations, suicide attempts, or self-harm.
Behavioral Medication History
Escitalopram (2019): 10 mg daily for 8 months. Minimal benefit. Discontinued.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Hospitalization:
None.
Current Medications
Omeprazole 20 mg daily
Family History
Social History
Education level: Associate degree in logistics.
Religious or Spiritual Involvement: Not religious.
Employment: Logistics coordinator, currently on a performance improvement plan.
Smoking Status: Never smoker. No vaping.
Alcohol use: Two beers on weekends.
Caffeine use: Four to five cups of coffee daily and one energy drink in the afternoon, which he says helps him focus.
Drug use: Daily cannabis from 2004 to 2017, used to "quiet his brain." No use since his son was born. No other drug use.
Abuse History: Denies history of abuse.
Substance Abuse History
Substance of choice: Cannabis.
History: Daily use for 13 years, meeting criteria for cannabis use disorder, now in sustained remission for nine years without treatment. State prescription monitoring program reviewed with no controlled substance prescriptions.
Cardiovascular Screening
BP: 138/86 mmHg
HR: 84 bpm
BMI: 31.2 kg/m²
Neck Circumference: 44 cm
ECG (today): Normal sinus rhythm at 82 bpm. PR 160 ms. QRS 92 ms. QTc 412 ms. No abnormalities.
Cardiac History: No chest pain, palpitations, syncope, or exercise intolerance.
Primary Care Labs (2026): TSH 1.9 uIU/mL. CBC and CMP normal. LDL 138 mg/dL.
Mental Status Exam
Appearance: Casually dressed, well groomed.
Behavior: Cooperative and engaged. Fidgeting with his pen and shifting in his chair throughout. Stood up twice during the interview.
Speech: Normal volume, rapid rate, with frequent tangents that he redirected himself.
Mood: "Frustrated but hopeful."
Affect: Full range and appropriate, with humor.
Thought Process: Circumstantial at times but goal-directed.
Thought Content: Focused on work concerns and his son. No suicidal or homicidal ideation. No delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Lost track of two questions mid-answer. Memory intact.
Insight: Good.
Judgment: Good.
Impulse Control: Mildly impaired, with interrupting during the interview.
Differential Diagnosis
ADHD, combined presentation: Most consistent with symptoms present since early childhood across multiple settings, supported by report cards, collateral history, DIVA-5, and CAARS.
Obstructive sleep apnea: Snoring, witnessed apneas, daytime sleepiness, and a STOP-BANG of 5 may worsen attention but would not explain childhood onset.
Anxiety and depressive disorders: Current mild symptoms are secondary to work stress and began long after ADHD symptoms.
Bipolar disorder: No history of manic or hypomanic episodes. MDQ negative.
Substance-related attention problems: No cannabis use in nine years, with symptoms present before and after use.
Risk Assessment
Risk Factors: Impulsive driving with three tickets and two collisions, job instability, and prior cannabis use disorder.
Protective Factors: Supportive wife, strong motivation for treatment, no suicidal ideation, and sustained remission from cannabis.
Assessment: Low acute risk. Outpatient care is appropriate.
Plan
Andy Comstock is a 41-year-old male with ADHD, combined presentation, meeting criteria in both childhood and adulthood, with impairment at work, while driving, and in his marriage, and with possible untreated obstructive sleep apnea.
1. ADHD, Combined Presentation, Moderate
Diagnosis is supported by childhood onset, report cards, collateral reports from his wife and mother, DIVA-5, and elevated self and observer CAARS scores. Untreated sleep apnea may add to his inattention and should be evaluated before starting a stimulant.
I discussed medication options with him:
He chose lisdexamfetamine once sleep apnea testing is complete.
2. Suspected Obstructive Sleep Apnea
Snoring, witnessed apneas, Epworth of 11, and STOP-BANG of 5 indicate high risk.
3. Cardiovascular Screening Before Stimulant Therapy
ECG is normal. Blood pressure is borderline at 138/86 mmHg, and his father had a heart attack at 52.
4. Cannabis Use Disorder, in Sustained Remission
5. Caffeine Use
High caffeine intake may raise heart rate and blood pressure once a stimulant is started.
6. Driving Safety
7. Follow Up
Chief Complaint
PTSD evaluation for nightmares, hypervigilance, avoidance, and increased drinking related to combat trauma.
History of Present Illness (HPI)
Pete Zimmerman is a 36-year-old male Army combat veteran who presents for a PTSD evaluation, referred by his primary care physician after worsening nightmares, irritability, and drinking over the past year.
He describes nightmares about a 2012 roadside bomb attack four to five nights weekly, startling at sudden noises, and avoiding crowds and fireworks. Symptoms worsened after a close friend from his unit died by suicide in November 2025. He drinks four to six beers most nights to sleep. He reports passing thoughts of not waking up, without intent or plan. He states, "I'm home, but part of me never left that road."
Trauma History
Index Trauma: In 06/2012, during deployment to Afghanistan, his vehicle was struck by a roadside bomb. He briefly lost consciousness, and a close friend in the vehicle was killed. He described the event briefly and chose not to share further details today, which was respected.
Other Combat Exposures: Repeated exposure to firefights and to wounded and killed service members during two deployments between 2010 and 2012.
Childhood: Denies abuse or neglect. Describes a stable home.
Life Events Checklist for DSM-5: Endorses combat exposure, sudden violent death of a close friend, and exposure to serious injury of others.
Primary Concerns and Reason for Evaluation
Diagnostic clarification and treatment for trauma-related symptoms that are straining his marriage, affecting his work as a utility lineman, and increasing his alcohol use.
Psychiatric History
2014: Onset of nightmares and irritability after returning home. Did not seek care.
2016: Honorable discharge from the Army after eight years of service.
2017 to 2019: Heavy drinking with divorce from his first wife in 2019. Experienced passive thoughts of death after the divorce. His primary care physician started sertraline.
2021: Stopped sertraline after partial improvement. Remarried and started work as a utility lineman.
07/2025: Fireworks on July 4 triggered a return of flashbacks and nightmares.
11/2025: A close friend from his unit died by suicide. Drinking and nightmares increased.
06/2026: Primary care restarted sertraline at 50 mg and increased to 100 mg in 08/2026, with minimal benefit so far.
No psychiatric hospitalizations or suicide attempts.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Sertraline (2019 to 2021): Up to 100 mg daily. Partial improvement in irritability. Self-discontinued.
Sertraline (06/2026 to present): Restarted at 50 mg, increased to 100 mg in 08/2026. Minimal benefit after 8 weeks at the current dose.
Zolpidem (2020): 5 mg at bedtime from primary care. Stopped after a night of sleepwalking.
Current Medications
Sertraline 100 mg daily
Ibuprofen 400 mg as needed for back pain
Family History
Family Details (current)
Married since 2021 and lives with his wife and 12-year-old stepdaughter. His wife is supportive and joined the end of today's visit. They have slept in separate rooms since 2025 because he kicks and shouts during nightmares. He worries his irritability is affecting his stepdaughter.
Social History
Education level: High school diploma and lineman apprenticeship.
Military History: U.S. Army infantry from 2008 to 2016, with deployments to Afghanistan in 2010 and 2012. Honorable discharge. Not enrolled in VA health care.
Religious or Spiritual Involvement: Raised Catholic. Stopped attending church after his friend's death.
Employment: Full-time utility lineman. Missed several shifts after heavy drinking nights this year.
Smoking Status: Uses nicotine pouches daily.
Alcohol use: Four to six beers most nights, more on weekends.
Caffeine use: Three energy drinks daily during work shifts.
Drug use: Denies cannabis or other drug use.
Abuse History: Denies history of abuse.
Firearms: Owns a handgun and a hunting rifle stored unlocked in his bedroom closet.
Substance Abuse History
Substance of choice: Alcohol.
History: Heavy drinking from 2017 to 2019, reduced from 2021 to 2024, and increased again since 2025. Uses alcohol to fall asleep and avoid nightmares. Meets 4 DSM-5 criteria for alcohol use disorder, including drinking more than intended, failed efforts to cut down, missed work, and continued use despite marital conflict. No withdrawal symptoms or seizures.
Psychometric Assessment
PTSD Checklist for DSM-5 (PCL-5): 58, well above the cutoff of 33 for probable PTSD.
Intrusions (Cluster B): 17 of 20
Avoidance (Cluster C): 7 of 8
Negative Changes in Mood and Thinking (Cluster D): 18 of 28
Arousal and Reactivity (Cluster E): 16 of 24
Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), Past Month: Total severity score 44. Meets criteria B, C, D, E, F, and G for PTSD. No dissociative subtype.
Interpretive Summary: Severe PTSD with prominent intrusive memories, nightmares, avoidance of reminders, guilt about his friend's death, and hyperarousal.
PHQ-9: 14, moderate depressive symptoms.
GAD-7: 13, moderate anxiety.
Insomnia Severity Index: 20, moderate clinical insomnia.
AUDIT: 14, harmful alcohol use.
Ohio State University TBI Identification Method: Positive for one blast injury with loss of consciousness under 5 minutes.
Montreal Cognitive Assessment: 27 of 30.
Columbia Suicide Severity Rating Scale Screener: Positive for wish to be dead in the past month. Negative for active ideation, method, intent, plan, or past behavior.
Mental Status Exam
Appearance: Muscular male in work clothes, appears tired, adequately groomed.
Behavior: Cooperative. Sat facing the door. Startled when a door closed in the hallway. Limited eye contact when discussing his friend.
Speech: Normal rate, low volume, terse answers about the trauma.
Mood: "On edge all the time."
Affect: Constricted and guarded, tearful briefly when discussing his friend's death.
Thought Process: Linear and goal-directed.
Thought Content: Survivor guilt and self-blame about the 2012 attack. Passive death wish without intent or plan. No homicidal ideation. No delusions.
Perceptual Disturbances: Intrusive images of the blast during the day. No hallucinations.
Cognition: Alert and oriented. Attention mildly reduced. Memory intact.
Insight: Fair to good. Recognizes alcohol is worsening his symptoms.
Judgment: Fair, given drinking and unsecured firearms.
Impulse Control: Fair, with reported irritability and verbal outbursts at home.
Differential Diagnosis
Posttraumatic stress disorder, chronic: Most consistent with exposure to a life-threatening event, symptoms in all four clusters for over 10 years, and PCL-5 and CAPS-5 results.
Major depressive disorder: Moderate depressive symptoms overlap with PTSD Cluster D and will be monitored.
Alcohol use disorder, moderate: Meets 4 criteria, with drinking used to manage nightmares and sleep.
Prolonged grief disorder: Grief over his friend's suicide is significant but occurs within the broader PTSD picture.
Persistent post-concussive symptoms: Mild TBI in 2012 with normal cognitive screening today, making it an unlikely primary cause.
Risk Assessment
Risk Factors: Male veteran, severe PTSD, passive death wish, friend's recent suicide, alcohol use disorder, unsecured firearms, and insomnia.
Protective Factors: Supportive wife, responsibility to his stepdaughter, stable employment, no prior attempts, and willingness to engage in treatment.
Assessment: Moderate chronic risk with low acute risk. Outpatient care is appropriate with close follow-up.
Safety Plan: Completed today with warning signs, coping strategies, and contacts, including the Veterans Crisis Line (dial 988, then press 1). He agreed to have his brother store both firearms at his home until his next visit, and his wife will confirm the transfer.
Plan
Pete Zimmerman is a 36-year-old male combat veteran with severe chronic PTSD, worsened by a friend's suicide and complicated by moderate alcohol use disorder, insomnia, and unsecured firearms.
1. Posttraumatic Stress Disorder, Chronic, Severe
PCL-5 of 58 and CAPS-5 severity of 44 confirm severe PTSD across all clusters. He has had minimal benefit from sertraline 100 mg and has never received trauma-focused therapy, which is the first-line treatment.
2. Trauma-Related Nightmares and Insomnia
Nightmares occur four to five nights weekly and drive his evening drinking.
3. Alcohol Use Disorder, Moderate
He drinks four to six beers most nights to sleep, with missed work and marital conflict. He has no opioid use, and liver function is normal.
4. Suicide Risk
Passive death wish since his friend's suicide, with unsecured firearms at home.
5. Veteran Resources and Peer Support
He is not enrolled in VA health care.
6. History of Mild Traumatic Brain Injury and Tinnitus
MoCA is 27 with no current cognitive concerns.
7. Follow Up
Chief Complaint
Three-month medication management visit for bipolar I disorder, with review of lithium level, kidney function, and calcium.
History of Present Illness (HPI)
Steve Gibson is a 46-year-old male with bipolar I disorder, stable on lithium since 2016, who presents for a three-month medication management visit and review of kidney and parathyroid labs.
He reports stable mood since a brief period of reduced sleep in May, with daily mood app ratings in the normal range for the past 90 days. He sleeps seven hours nightly and is working full time. He notes urinating often, a fine hand tremor when typing, and mild fatigue. He denies depressed mood, racing thoughts, or impulsive spending. He states, "Lithium gave me my life back, so I'm nervous about anything that means changing it."
Psychotherapy Summary
We spent 20 minutes reviewing his relapse prevention plan with his wife present. He identified his earliest warning signs from past episodes: sleeping under six hours for two nights, starting several new projects at once, and talking faster on the phone. His wife added that he becomes unusually generous with money.
We reviewed what happened in May, when he slept five hours a night for six days during a busy work period. He recognized the pattern early, used his rescue plan, and called the clinic, which prevented a full episode. We discussed how his lab results may lead to treatment changes over time and that any change would be gradual and shared. He was reassured, stating, "As long as we're watching it together, I can handle that."
Mood Episode Timeline
2001: First manic episode at age 21 with grandiosity, no sleep for four days, heavy spending, and psychotic features. Hospitalized for 10 days. Diagnosed with bipolar I disorder. Started olanzapine and valproate.
2003: Major depressive episode after stopping medications on his own. Treated as an outpatient.
2006: Second manic episode with psychotic features after stopping medications. Hospitalized for 8 days. Restarted valproate with quetiapine.
2006 to 2015: Fewer episodes but ongoing weight gain of 14 kg and prediabetes.
2016: Transitioned to lithium for stronger relapse prevention and fewer metabolic effects. Valproate tapered off, and quetiapine stopped in 2017.
2019: Moderate depressive episode. Lamotrigine added, with remission by 2020.
05/2026: Six days of reduced sleep and increased goal-directed activity during a high-stress period at work. Did not meet full criteria for hypomania. Resolved with a short course of quetiapine at bedtime.
No hospitalizations since 2006.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
Previous Psychiatric or Mental Health Hospitalization:
Behavioral Medication History
Olanzapine (2001 to 2006): 15 mg nightly. Effective for mania. Discontinued for 12 kg weight gain.
Valproate (2001 to 2016): Up to 1500 mg daily. Partial prevention of episodes. Weight gain and hair thinning.
Quetiapine (2006 to 2017): Up to 300 mg nightly. Effective for sleep and mood. Discontinued for sedation and prediabetes.
Lithium carbonate (2016 to present): 1200 mg daily from 2016 to 2024, reduced to 900 mg extended-release at bedtime in 2024 for declining kidney function. Highly effective, with no hospitalizations since starting.
Lamotrigine (2019 to present): Titrated to 200 mg daily. Effective for depressive episodes. No rash.
Quetiapine (05/2026): 50 mg at bedtime for one week as a rescue medication. Effective.
Current Medications
Lithium carbonate extended-release 900 mg at bedtime
Lamotrigine 200 mg daily
Levothyroxine 75 mcg daily
Atorvastatin 10 mg nightly
Quetiapine 50 mg at bedtime as needed per rescue plan
Family History
Family Details (current)
Married for 15 years and lives with his wife and two teenage sons. His wife is closely involved in his care and attended today's visit. She tracks his sleep with him and knows his rescue plan.
Social History
Education level: Bachelor's degree in business.
Religious or Spiritual Involvement: Attends a Lutheran church with his family.
Employment: Full-time regional sales manager.
Smoking Status: Never smoker.
Alcohol use: Rarely, a few times per year.
Caffeine use: One cup of coffee in the morning, none after noon.
Drug use: Denies cannabis or other drug use.
Abuse History: Denies history of abuse.
Firearms: No firearms in the home.
Substance Abuse History
Substance of choice: None.
History: No history of substance use disorder.
Mood Charting Summary
Daily mood app ratings from the past 90 days show 84 days in the normal range, 6 days of mild elevation in May, and no days of low mood lasting more than two consecutive days. Average sleep from his wearable device is 7.1 hours nightly over the past 30 days.
Psychometric Scores
Young Mania Rating Scale: 3, no current manic symptoms.
Quick Inventory of Depressive Symptomatology (QIDS-SR16): 4, no depression.
PHQ-9: 3.
Columbia Suicide Severity Rating Scale Screener: Negative.
Vitals
BP: 128/80 mmHg
HR: 66 bpm
Weight: 92 kg (90 kg in 2025)
BMI: 29.1 kg/m²
Medication Monitoring Labs
Lithium Level, 12-Hour Trough:
Kidney Function (eGFR in mL/min/1.73 m²):
Urine Albumin-to-Creatinine Ratio (10/2026): 18 mg/g
Calcium and Parathyroid Hormone:
Thyroid Function (10/2026): TSH 2.4 uIU/mL, free T4 1.2 ng/dL on levothyroxine.
Metabolic Labs (10/2026): HbA1c 5.8%. LDL 128 mg/dL. Triglycerides 180 mg/dL.
Mental Status Exam
Appearance: Well groomed in business casual clothing.
Behavior: Cooperative, calm, with good eye contact. Fine tremor of both hands when holding his phone.
Speech: Normal rate, rhythm, and volume.
Mood: "Steady."
Affect: Euthymic, full range, and appropriate.
Thought Process: Linear and goal-directed.
Thought Content: Focused on lab results and work. No grandiosity. No suicidal or homicidal ideation. No delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Attention and memory intact.
Insight: Excellent. Knows his warning signs and rescue plan.
Judgment: Good.
Impulse Control: Good.
Risk Assessment
Risk Factors: Bipolar I disorder with prior psychotic mania and a family history of suicide.
Protective Factors: Ten years of stability on lithium, strong insight, engaged spouse, stable employment, no substance use, and no firearms in the home.
Assessment: Low acute risk. Outpatient care is appropriate.
Plan
Steve Gibson is a 46-year-old male with bipolar I disorder who has been stable on lithium for ten years, now with slowly declining kidney function and new hypercalcemia linked to lithium.
1. Bipolar I Disorder, Most Recent Episode Hypomanic, in Partial Remission
He is euthymic with a YMRS of 3 and QIDS of 4, and his brief period of reduced sleep in May was managed early without a full episode. Lithium has prevented hospitalization for ten years after two prior manic episodes with psychosis.
2. Chronic Kidney Disease Stage 3a Associated with Lithium
eGFR has declined from 98 to 58 over ten years, with a slower decline since the 2024 dose reduction. Albuminuria is minimal. I discussed continuing lithium at a lower level against switching to other mood stabilizers, which carry higher relapse risk for him. He chose to continue lithium with closer monitoring.
3. Hypercalcemia with Elevated Parathyroid Hormone
Calcium has risen to 10.7 mg/dL with a parathyroid hormone of 88 pg/mL, consistent with lithium-associated hyperparathyroidism.
4. Lithium-Induced Hypothyroidism
TSH is 2.4 uIU/mL on levothyroxine.
5. Lithium-Related Polyuria and Tremor
He urinates about 2.5 liters daily and wakes twice at night. A fine postural tremor affects typing.
6. Metabolic Monitoring
LDL is 128 mg/dL and HbA1c is 5.8%, with a 2 kg weight gain this year.
7. Relapse Prevention Plan
8. Follow Up
Chief Complaint
Geriatric psychiatry evaluation of agitation, nighttime wandering, and delusions of theft in moderate Alzheimer's dementia.
History of Present Illness (HPI)
Addison Hurley is a 79-year-old female with moderate Alzheimer's dementia who presents with her daughter for a geriatric psychiatry evaluation of agitation, nighttime wandering, and accusations of theft that have escalated since July 2026.
Her daughter reports she accuses family of stealing her purse daily, becomes combative during evening baths, and has tried to leave the house at 2 AM twice. Lorazepam started at urgent care in August was followed by a fall and more confusion. Addison says her knees hurt when she walks. She denies feeling sad or seeing things that others do not. She states, "Someone keeps moving my things, and nobody believes me."
Caregiver Report
Daughter (primary caregiver, interviewed separately): Behaviors cluster between 4:00 PM and 9:00 PM. Accusations of theft occur when Addison cannot find her purse, which she hides in different places each day. Agitation is worst during evening baths, when she has pushed her daughter twice. She paces the hallway after dinner and tries the front door at night. Episodes ease with her favorite 1950s music and looking at family photos. The daughter reports exhaustion and feeling "like a stranger in my mother's eyes."
Behavior Triggers Identified:
Behavioral Symptom History
2020: Repeating questions and misplacing items. Noticed by her husband.
2022: Neurology evaluation with MoCA 21 of 30, MRI showing hippocampal atrophy, and a positive amyloid PET. Diagnosed with mild Alzheimer's dementia. Donepezil started.
2023: Stopped driving after getting lost in her own neighborhood. Husband died that year.
2024: Moved in with her daughter. MoCA 16 of 30. Memantine added.
2025: Began accusing family of moving or taking belongings. Evening restlessness started.
07/2026: Agitation escalated during evening baths. Tried to leave the house at night twice.
08/2026: Urgent care prescribed lorazepam 0.5 mg at bedtime. Fell in the bathroom one week later without fracture. Daughter noticed more daytime confusion.
09/2026: Neurology referred her to geriatric psychiatry.
Psychiatric History
No psychiatric diagnoses or treatment before dementia. No history of depression, psychosis, hospitalization, or suicide attempts.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
None before this evaluation.
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Donepezil (2022 to present): 10 mg nightly. Tolerated without GI side effects.
Memantine (2024 to present): 10 mg twice daily. Tolerated.
Lorazepam (08/2026 to present): 0.5 mg at bedtime from urgent care. Followed by a fall and increased confusion.
Current Medications
Donepezil 10 mg nightly
Memantine 10 mg twice daily
Lorazepam 0.5 mg at bedtime
Amlodipine 5 mg daily
Alendronate 70 mg weekly
Calcium carbonate 600 mg with vitamin D3 800 IU daily
Family History
Family Details (current)
Widowed since 2023. Lives with her daughter, her daughter's husband, and their teenage son in a two-story home. Her daughter works part time from home and is her durable power of attorney and health care proxy. Her son lives out of state and calls weekly.
Social History
Education level: High school diploma.
Religious or Spiritual Involvement: Lifelong Baptist. Enjoys hymns and attending church with her daughter.
Employment: Retired school cafeteria manager.
Smoking Status: Never smoker.
Alcohol use: None.
Caffeine use: One cup of coffee in the morning.
Drug use: None.
Abuse History: No concerns for abuse or neglect identified on caregiver and patient interview.
Firearms: No firearms in the home.
Driving: Stopped driving in 2023.
Substance Abuse History
Substance of choice: None.
History: No history of substance use.
Functional Status
Activities of Daily Living: Needs help choosing clothes and full assistance with bathing. Feeds herself and toilets independently with occasional nighttime accidents.
Instrumental Activities of Daily Living: Dependent for medications, finances, cooking, shopping, and transportation.
Psychometric and Cognitive Assessment
Montreal Cognitive Assessment: 21 of 30 (2022), 16 of 30 (2024), 11 of 30 (today).
Functional Assessment Staging Tool (FAST): Stage 5, moderate dementia.
Neuropsychiatric Inventory Questionnaire (NPI-Q): Severity 16 and caregiver distress 22. Highest in nighttime behaviors, agitation, delusions, and aberrant motor behavior.
Cohen-Mansfield Agitation Inventory: 62, with physically non-aggressive behaviors such as pacing and trying to leave, along with verbal agitation.
Cornell Scale for Depression in Dementia: 9, mild depressive symptoms with irritability and poor sleep.
Pain Assessment in Advanced Dementia (PAINAD): 0 at rest, 4 while walking.
Zarit Burden Interview (daughter): 24, high caregiver burden.
Interpretive Summary: Moderate Alzheimer's dementia with significant agitation, delusions of theft, and sleep disruption clustered in the evening, with untreated pain and benzodiazepine use as likely contributors.
Medical Workup
Labs (09/2026): CBC and CMP within normal limits. Sodium 138 mmol/L. TSH 2.1 uIU/mL. Vitamin B12 520 pg/mL. Urinalysis negative for infection.
ECG (today): Normal sinus rhythm. QTc 432 ms.
MRI Brain (2022): Bilateral hippocampal atrophy. Mild small vessel changes.
Amyloid PET (2022): Positive for cortical amyloid deposition.
Mental Status Exam
Appearance: Neatly dressed with help from her daughter. Appears her stated age.
Behavior: Pleasant and engaged early in the visit. Became restless after 30 minutes and asked twice where her purse was.
Speech: Fluent with word-finding pauses. Normal rate and volume.
Mood: "Fine, just tired of people taking my things."
Affect: Mildly irritable, brightening when discussing her grandson.
Thought Process: Tangential at times, redirectable.
Thought Content: Fixed belief that family members take her belongings. No suicidal or homicidal ideation.
Perceptual Disturbances: No hallucinations reported or observed.
Cognition: Oriented to person only. Could not recall any of three words. Impaired attention and executive function.
Insight: Poor. Does not recognize memory loss.
Judgment: Impaired.
Impulse Control: Mildly impaired in the evening per caregiver report.
Decision-Making Capacity
She could not describe her medications or weigh treatment options and does not have capacity for complex medical decisions. She was able to express preferences, including wanting to stay home with her daughter and hear her music. Her daughter, as health care proxy, participated in all decisions today.
Differential Diagnosis
Agitation and psychosis due to Alzheimer's dementia: Most consistent with evening-predominant agitation, delusions of theft linked to misplacing items, and progression with cognitive decline.
Delirium: Less likely with normal labs, negative urinalysis, and no acute change in attention outside the evening, although lorazepam may have added confusion.
Dementia with Lewy bodies: Less likely without visual hallucinations, parkinsonism, or REM sleep behavior.
Depression in dementia: Mild symptoms on the Cornell Scale, which may add to irritability.
Pain-related agitation: Likely contributor, with PAINAD of 4 while walking.
Risk Assessment
Risk Factors: Nighttime wandering with door-seeking, recent fall on lorazepam, physical aggression during bathing, and high caregiver burden.
Protective Factors: Devoted family caregivers, no firearms in the home, no prior self-harm, and response to music and familiar routines.
Assessment: Moderate risk for wandering and falls. Low risk of harm to self or others with a safety plan in place.
Plan
Addison Hurley is a 79-year-old female with moderate Alzheimer's dementia and evening agitation, delusions of theft, and wandering, with untreated knee pain and recent lorazepam use as likely contributors.
1. Agitation and Delusions of Theft in Alzheimer's Dementia
Behaviors follow predictable evening triggers, and non-drug strategies are first-line. A low-dose antidepressant may help agitation and mild depressive symptoms with lower risk than antipsychotics.
2. Lorazepam Use
Lorazepam is linked to her recent fall and worsened confusion.
3. Knee Osteoarthritis Pain
PAINAD rises to 4 with walking, and pain likely worsens evening restlessness.
4. Sleep Disruption and Sundowning
5. Wandering and Home Safety
6. Caregiver Burden
Her daughter's Zarit score of 24 indicates high burden.
7. Cognitive Medications
8. Advance Care Planning
Her daughter is a health care proxy and durable power of attorney.
9. Follow Up
Chief Complaint
Evaluation for opioid use disorder and buprenorphine initiation after a nonfatal fentanyl overdose.
History of Present Illness (HPI)
Joel Moore is a 31-year-old male with opioid use disorder who presents for evaluation and buprenorphine treatment after a nonfatal fentanyl overdose in August 2026, his second since 2022.
He smokes about 1 gram of fentanyl daily and last used 18 hours ago. He reports chills, aching legs, a runny nose, and restlessness that began this morning. He also uses cannabis nightly and smokes a pack of cigarettes daily. He denies alcohol, stimulant, or benzodiazepine use and denies suicidal thoughts. His sister drove him today. He states, "I woke up on the bathroom floor with my sister crying, and I'm done living like this."
Psychotherapy Summary
We used motivational interviewing to explore what brought him in today. He described the August overdose as a turning point, especially seeing his sister's fear. He rated his readiness to stop fentanyl as 9 out of 10 and his confidence as 6 out of 10, citing past relapse after leaving methadone.
We explored what helped during his six months on methadone in 2023, including daily structure and steady work, and what led to dropout, mainly a clinic schedule that conflicted with his job. He identified office-based buprenorphine as a better fit. We discussed what to expect during induction, and he chose to start today. He said, "If I can work and still get treatment, I can actually stick with it."
Substance Use History
2017: L4-L5 disc herniation from a warehouse injury. Prescribed oxycodone 10 mg four times daily by his primary care physician for 18 months.
2019: Oxycodone stopped abruptly when his prescriber retired. Began buying oxycodone pills from friends.
2021: Switched to counterfeit pills containing fentanyl, then to smoking fentanyl powder.
03/2022: First overdose. Revived with naloxone by a friend and treated in the emergency department.
2023: Enrolled in a methadone program for six months, stabilized on 80 mg daily. Left the program due to a schedule conflict with work and relapsed within two weeks.
2023: Positive hepatitis C antibody and RNA during methadone intake. Not treated.
2024 to 2026: Daily fentanyl use, increasing to about 1 gram per day.
08/2026: Second overdose. His sister gave two doses of nasal naloxone before EMS arrived. Discharged from the emergency department with a naloxone kit and referral to this clinic.
Current Use Pattern
Fentanyl: About 1 gram daily, smoked. Last use 18 hours ago.
Cannabis: Smoked nightly for sleep, about 1 gram.
Nicotine: One pack of cigarettes daily since age 16.
Alcohol: Denies use since 2021.
Stimulants: Denies use. Tried cocaine twice in 2015.
Benzodiazepines: Denies use.
Injection Drug Use: Injected heroin and fentanyl from 2021 to 2022. Denies injection since. Reports no needle sharing since 2022.
DSM-5 Criteria for Opioid Use Disorder
Larger amounts or longer than intended: Met
Persistent desire or failed efforts to cut down: Met
Great deal of time obtaining, using, or recovering: Met
Craving: Met
Failure to fulfill major role obligations: Met
Continued use despite social problems: Met
Important activities given up: Met
Recurrent use in physically hazardous situations: Met
Continued use despite physical or psychological problems: Met
Tolerance: Not counted, as initial use was under medical supervision
Withdrawal: Not counted, as initial use was under medical supervision
Total: 9 of 11 criteria met, consistent with severe opioid use disorder.
Psychiatric History
Depressive symptoms since 2019. Never formally diagnosed or treated. No psychiatric hospitalizations. Both overdoses were unintentional, which he and his sister confirm. No history of suicide attempts or self-harm.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Oxycodone (2017 to 2019): 10 mg four times daily for back pain. Stopped abruptly.
Methadone (2023): Titrated to 80 mg daily. Effective for cravings. Left treatment after six months.
Buprenorphine: Never prescribed.
Current Medications
Ibuprofen 400 mg as needed for back pain
Naloxone 4 mg nasal spray, from the emergency department
Family History
Family Details (current)
Lives with his older sister and her two young children since 08/2026. His sister is supportive and attended the second half of today's visit. Single, with no children. His brother has offered to be a recovery support.
Social History
Education level: High school diploma.
Religious or Spiritual Involvement: Not religious.
Employment: Works part time at an auto repair shop. Lost his warehouse job in 2024 due to missed shifts.
Housing: Stable with his sister.
Insurance: Medicaid.
Transportation: No car. Relies on his sister and Medicaid transportation.
Smoking Status: One pack of cigarettes daily.
Alcohol use: None since 2021.
Caffeine use: Two energy drinks daily.
Abuse History: Denies history of abuse.
Legal: No current legal issues.
Withdrawal Assessment
Clinical Opiate Withdrawal Scale (COWS):
10:00 AM: 11, mild withdrawal, with sweating, restlessness, runny nose, and bone aches
11:30 AM: 14, moderate withdrawal, with added yawning and gooseflesh
12:30 PM: 7, after first buprenorphine dose
1:30 PM: 3, after second buprenorphine dose
Labs and Monitoring
Point-of-Care Urine Drug Screen (today): Positive for fentanyl and cannabinoids. Negative for buprenorphine, methadone, oxycodone, morphine, cocaine, amphetamines, and benzodiazepines. Confirmatory testing sent.
Prescription Drug Monitoring Program (today): No controlled substance prescriptions since 2019.
Hepatitis C (2023): Antibody positive. RNA 1.2 million IU/mL, genotype 1a.
Hepatitis B (2023): Surface antigen negative. Surface antibody negative, not immune.
HIV (2023): Negative.
Comprehensive Metabolic Panel (08/2026): AST 49 U/L (high). ALT 58 U/L (high). Albumin 4.1 g/dL. Bilirubin 0.8 mg/dL.
CBC (08/2026): Within normal limits. Platelets 212 x 10^3/μL.
Psychometric Scores
PHQ-9: 12, moderate depressive symptoms.
GAD-7: 10, moderate anxiety.
AUDIT-C: 0.
Columbia Suicide Severity Rating Scale Screener: Negative.
Mental Status Exam
Appearance: Thin male in a hooded sweatshirt, mildly diaphoretic.
Behavior: Cooperative but restless, shifting in his seat and yawning often.
Speech: Normal rate and volume.
Mood: "Sick and nervous."
Affect: Anxious, congruent, with appropriate tearfulness when discussing his sister.
Thought Process: Linear and goal-directed.
Thought Content: Focused on withdrawal and starting treatment. No suicidal or homicidal ideation. No delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Attention mildly reduced due to withdrawal.
Insight: Good. Recognizes the danger of fentanyl and the need for treatment.
Judgment: Improving, as shown by seeking care.
Impulse Control: Fair.
Differential Diagnosis
Opioid use disorder, severe: Meets 9 of 11 DSM-5 criteria, with two overdoses.
Opioid withdrawal: Confirmed by rising COWS scores 18 hours after last fentanyl use.
Cannabis use disorder, mild: Nightly use for sleep, to be assessed further.
Tobacco use disorder: Daily cigarette use since adolescence.
Major depressive disorder: Moderate symptoms that may be substance-related, to be reassessed after four weeks of stability.
Risk Assessment
Risk Factors: Recent fentanyl overdose, ongoing daily fentanyl use, prior injection use, reduced tolerance after treatment interruptions, and depressive symptoms.
Protective Factors: Strong motivation, supportive sister and brother, stable housing, part-time work, and prior response to opioid agonist treatment.
Assessment: High risk of accidental overdose. Low risk of intentional self-harm.
Plan
Joel Moore is a 31-year-old male with severe opioid use disorder from fentanyl, with two nonfatal overdoses, who started buprenorphine in clinic today after reaching moderate withdrawal.
1. Opioid Use Disorder, Severe, Fentanyl
He reached a COWS of 14 at 11:30 AM, allowing safe initiation without precipitated withdrawal. Buprenorphine was chosen over methadone to fit his work schedule.
2. Overdose Prevention and Harm Reduction
3. Chronic Hepatitis C
Untreated since 2023, with mildly elevated liver enzymes.
4. Infectious Disease Prevention
5. Tobacco Use Disorder
6. Depressive and Anxiety Symptoms
7. Chronic Low Back Pain
8. Follow Up
Chief Complaint
Worsening depression over four months following her father's death, with low motivation, oversleeping, and passive thoughts of death.
History of Present Illness (HPI)
Sabrina Bergling is a 38-year-old female with recurrent major depressive disorder, with episodes in 2016 and 2020, who presents for an initial psychiatric evaluation of worsening depression over the past four months.
Since her father died in May 2026, she reports low mood most days, loss of interest in painting and her children's activities, sleeping 10 to 11 hours, and a 6 kg weight gain. She feels "heavy" and crushed by small criticisms at work. She has passive thoughts that her family would be better off without her, with no intent or plan. Her evening wine intake has increased. She states, "I know what depression feels like, and this is the deepest it's ever been."
Psychotherapy Summary
We explored her grief over her father's death from pancreatic cancer in May 2026 and her guilt about not visiting more often during his final months. She described a recurring thought that she "fails everyone she loves," which intensifies after minor feedback at work. We identified this as a self-critical pattern consistent with her prior episodes.
We reviewed how oversleeping, withdrawal from painting, and evening wine use are maintaining her low mood. We introduced behavioral activation and planned two small, valued activities for the coming week: painting for 20 minutes on Saturday morning and walking her children to school twice. She was tearful when discussing her father and visibly calmer after completing her safety plan, stating, "Having a plan written down helps me feel less trapped."
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
2016: First major depressive episode with postpartum onset after the birth of her first child. Treated with sertraline and supportive counseling, with full remission by 2017.
2020: Second major depressive episode after losing her job during the pandemic. Treated with escitalopram and 12 sessions of CBT, with partial response and remission by mid-2021.
2023: Tapered off escitalopram with her primary care physician due to sexual side effects and weight gain. Remained well until 2026.
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Sertraline (2016 to 2017): Titrated to 100 mg daily. Full response. Mild sexual side effects. Discontinued after 12 months of remission.
Escitalopram (2020 to 2023): Titrated to 20 mg daily. Partial response. Discontinued for sexual dysfunction and 5 kg weight gain.
Trazodone (2020): 50 mg at bedtime for sleep. Discontinued after two weeks for morning grogginess.
Family History
Family Details (current)
Married for 12 years and lives with her husband and two children, ages 10 and 7. Her husband is supportive, attended the first half of today's visit, and reports she has "stopped being herself" since the summer. Her mother lives 20 minutes away and has been grieving as well.
Sexual Activity
Sexually active with her husband. Reports decreased libido over four months. Sexual side effects with both prior SSRIs were a main reason for stopping treatment.
Social History
Education level: Bachelor's degree in graphic design.
Religious or Spiritual Involvement: Raised Methodist. Attends church occasionally and finds it comforting.
Employment: Works full time as a senior graphic designer. Missed four days of work in the past month and received critical feedback on a recent project.
Smoking Status: Never smoker. No vaping.
Alcohol use: Increased from one glass of wine on weekends to two to three glasses most evenings since June 2026.
Caffeine use: Two cups of coffee each morning.
Drug use: Denies cannabis or other drug use.
Abuse History: Denies history of physical, sexual, or emotional abuse.
Firearms: Husband owns two hunting rifles stored in a locked safe.
Substance Abuse History
Substance of choice: Alcohol.
History: No prior concerns before 2026. No withdrawal symptoms, blackouts, or legal problems. AUDIT-C score of 5, consistent with hazardous use. Family history of alcohol use disorder increases risk.
Psychometric Assessment
PHQ-9: 19, moderately severe depression. Item 9 positive for thoughts that she would be better off dead on several days.
GAD-7: 11, moderate anxiety.
Mood Disorder Questionnaire: 3 of 13, negative screen for bipolar spectrum disorder.
AUDIT-C: 5, hazardous alcohol use.
Columbia Suicide Severity Rating Scale Screener: Positive for wish to be dead. Negative for active ideation, method, intent, plan, or past behavior.
MMPI-2 (completed 09/2026):
Validity Scales: L 48, F 62, K 45. Valid profile without over-reporting or defensiveness.
Scale 2 (Depression): T-score 78, clinically elevated. Reflects pervasive sadness, low energy, hopelessness, and loss of interest.
Scale 7 (Psychasthenia): T-score 71, clinically elevated. Reflects worry, self-doubt, rumination, and self-critical thinking.
Scale 8 (Schizophrenia): T-score 58, within normal limits. No evidence of thought disorder.
Scale 9 (Hypomania): T-score 42, low. No evidence of hypomanic energy or activation.
Interpretive Summary: Internalizing profile with prominent depression and anxious rumination, consistent with a self-critical cognitive style. No indication of psychosis or bipolar-spectrum features.
Medical Workup
Primary Care Labs (08/2026): TSH 2.3 uIU/mL. CBC and CMP within normal limits. Vitamin B12 410 pg/mL. 25-hydroxyvitamin D 18 ng/mL (low). Urine pregnancy test negative.
Mental Status Exam
Appearance: Casually dressed, adequately groomed. Appears tired.
Behavior: Cooperative with reduced eye contact. Mild psychomotor slowing.
Speech: Slowed rate, soft volume, with long pauses before answering.
Mood: "Empty and heavy."
Affect: Constricted, dysphoric, and tearful when discussing her father. Brightens briefly when discussing her children.
Thought Process: Linear and goal-directed.
Thought Content: Themes of guilt, worthlessness, and failure. Passive death wish without intent or plan. No homicidal ideation. No delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Attention reduced on serial sevens. Memory grossly intact.
Insight: Good. Recognizes this as a depressive episode.
Judgment: Fair, given increased alcohol use to manage mood.
Impulse Control: Good.
Differential Diagnosis
Major depressive disorder, recurrent, severe, with atypical features and anxious distress: Most consistent with three discrete episodes, hypersomnia, weight gain, leaden fatigue, and rejection sensitivity.
Bipolar II disorder: Considered given her brother's bipolar I disorder. No history of hypomania, MDQ negative, and MMPI-2 Scale 9 low.
Prolonged grief disorder: Grief is a clear trigger, but symptoms extend well beyond grief and have lasted four months.
Alcohol-induced depressive disorder: Less likely, as depression preceded the increase in alcohol use and her prior episodes occurred without alcohol.
Depression due to a medical condition: Thyroid function and B12 are normal.
Risk Assessment
Risk Factors: Current severe depressive episode, passive death wish, recent bereavement, increased alcohol use, firearms in the home, and family history of mood disorders.
Protective Factors: Strong connection to her children and husband, no history of suicide attempts, good insight, engagement in treatment, and religious involvement.
Assessment: Low to moderate acute risk. Outpatient care is appropriate. Safety plan completed today with warning signs, coping strategies, contacts, and 988 Suicide and Crisis Lifeline information. Her husband agreed to change the safe combination and move ammunition to her brother-in-law's home.
Plan
Sabrina Bergling is a 38-year-old female with recurrent major depressive disorder presenting with her third and most severe episode, triggered by her father's death and complicated by increased alcohol use and passive thoughts of death.
1. Major Depressive Disorder, Recurrent, Severe, Without Psychotic Features, with Atypical Features and Anxious Distress
She meets criteria for a severe recurrent episode with PHQ-9 of 19 and MMPI-2 Scale 2 at a T-score of 78. Prior SSRIs worked but were stopped for sexual side effects and weight gain. Vortioxetine carries lower rates of both and may help her concentration.
2. Hazardous Alcohol Use
Her alcohol intake has tripled since June 2026 and is worsening her mood and sleep.
3. Suicide Risk
Passive death wish without intent or plan, with firearms secured during today's visit.
4. Bereavement
Her grief over her father's death is a central theme and an ongoing trigger.
5. Monitoring for Bipolar Spectrum Symptoms
Her brother's bipolar I disorder raises her risk of antidepressant-related activation.
6. Vitamin D Deficiency
Vitamin D level of 18 ng/mL may be adding to fatigue.
7. Follow Up
Chief Complaint
Follow-up for generalized anxiety and panic disorder, with medication management and CBT session 6.
History of Present Illness (HPI)
Addison Wentz is a 29-year-old female with generalized anxiety disorder and panic disorder who presents for medication management and her sixth CBT session in the current treatment course.
She reports two panic attacks in the past month, down from six in June, both while driving on the interstate. Worry about her new team lead role keeps her awake about an hour most nights. She used lorazepam three times this month. She completed her exposure goal of driving two exits on the interstate with her partner. She denies depressed mood, suicidal thoughts, or alcohol use to cope. She states, "My heart still races on the ramp, but I didn't turn around this time."
Psychotherapy Summary
We reviewed her exposure homework. She drove two exits on the interstate with her partner on three occasions. Peak distress fell from 80 to 55 on a 0 to 100 scale by the third drive, and she did not exit early or use lorazepam during any of them.
We used cognitive restructuring on her belief that a racing heart means she will lose control of the car. She identified evidence against this belief, including more than 40 panic attacks without losing control and a normal cardiac workup in 2022. She reframed the thought as "My body is having an alarm reaction, and I can keep driving through it."
We completed interoceptive exposure with 60 seconds of breathing through a straw and 30 seconds of spinning in a chair. Distress ratings dropped from 70 to 40 across three trials. We discussed how lorazepam use before drives acts as a safety behavior that limits new learning.
For worry about work, we introduced a 20-minute worry postponement period at 6:00 PM. She engaged well, appeared more confident by the end of the session, and said, "It helps to see that my body is the problem, not the road."
Exposure Hierarchy
Drive on side streets alone: Distress 15, mastered
Drive on a highway frontage road alone: Distress 30, mastered
Drive two interstate exits with partner: Distress 55, current step
Drive two interstate exits alone with partner following: Distress 70, next step
Drive four interstate exits alone: Distress 85
Drive on the interstate during rush hour alone: Distress 95
Psychiatric History
2011: Excessive worry about school and family with frequent stomachaches. Met with the school counselor.
2016: Diagnosed with generalized anxiety disorder by college student health. Completed six counseling sessions.
03/2022: First panic attack while driving on the interstate. Emergency department visit with normal ECG, troponin, and TSH. A second emergency visit followed in 06/2022 with the same results. Began avoiding highways.
01/2023: Began psychiatric care. Diagnosed with panic disorder and generalized anxiety disorder. Started sertraline.
2024: Completed 12 sessions of CBT for panic disorder. Panic attacks decreased from eight to one per month, and she resumed limited highway driving.
2025: Prescribed lorazepam at urgent care after a panic attack during a flight. Used once or twice monthly.
05/2026: Promoted to team lead. Worry, insomnia, and panic attacks increased to six per month, and highway avoidance returned.
08/2026: Resumed weekly CBT with exposure-based treatment.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Sertraline (2023 to present): Started at 50 mg, increased to 100 mg in 2023 and 150 mg in 2024. Good response with mild early nausea.
Lorazepam (2025 to present): 0.5 mg as needed, prescribed by urgent care. Used one to three times monthly.
Hydroxyzine (2023): 25 mg as needed. Effective but caused next-day drowsiness at bedtime doses.
Current Medications
Sertraline 150 mg daily
Lorazepam 0.5 mg as needed for panic
Albuterol HFA 90 mcg as needed for wheezing
Levonorgestrel intrauterine device
Family History
Social History
Education level: Bachelor's degree in accounting.
Religious or Spiritual Involvement: Not religious. Practices yoga weekly.
Employment: Works as a team lead at an accounting firm since 05/2026. Hybrid schedule with a 35-minute commute that includes the interstate.
Living Situation: Lives with her partner of four years.
Smoking Status: Never smoker. No vaping.
Alcohol use: One to two drinks on weekends.
Caffeine use: One cup of coffee in the morning, reduced from three in 2024.
Drug use: Denies cannabis or other drug use.
Abuse History: Denies history of abuse.
Substance Abuse History
Substance of choice: None.
History: No history of substance use disorder. State prescription monitoring program reviewed today, showing lorazepam from a single prescriber with no early refills.
Psychometric Scores
GAD-7: 06/2026: 16. 08/2026: 14. 09/2026: 13. Today: 12.
Panic Disorder Severity Scale: 06/2026: 15. 08/2026: 13. 09/2026: 11. Today: 9.
Panic Attacks per Month: 06/2026: 6. 08/2026: 4. 09/2026: 3. Today: 2.
PHQ-9: 06/2026: 7. Today: 5.
Insomnia Severity Index: 06/2026: 16. Today: 14.
Columbia Suicide Severity Rating Scale Screener: Negative.
Medical Workup
Emergency Department Evaluations (03/2022 and 06/2022): ECG with normal sinus rhythm. Troponin negative. TSH 1.8 uIU/mL.
Echocardiogram (2022): Normal structure and function.
Primary Care Labs (2026): TSH 2.0 uIU/mL. CBC normal.
Mental Status Exam
Appearance: Well groomed and dressed in business casual attire.
Behavior: Cooperative with good eye contact. Mild restlessness early in the session that settled by the end.
Speech: Normal rate and volume, slightly rapid when describing driving.
Mood: "Anxious, but better than last month."
Affect: Anxious, congruent with content, and brighter when reviewing progress.
Thought Process: Linear and goal-directed.
Thought Content: Worry centered on work performance and fear of panic while driving. No suicidal or homicidal ideation. No obsessions or delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Attention and memory intact.
Insight: Good. Understands the panic cycle and the role of avoidance.
Judgment: Good.
Impulse Control: Good.
Risk Assessment
Risk Factors: Anxiety disorders and increased work stress.
Protective Factors: Supportive partner, stable employment, strong engagement in therapy, no suicidal ideation, and no substance misuse.
Assessment: Low acute risk. Outpatient care remains appropriate.
Plan
Addison Wentz is a 29-year-old female with generalized anxiety disorder and panic disorder with driving-related avoidance, showing steady improvement in panic frequency and severity with residual worry and insomnia.
1. Generalized Anxiety Disorder
GAD-7 has improved from 16 to 12 but remains in the moderate range, with work-related worry driving insomnia. She has tolerated sertraline 150 mg well for two years.
2. Panic Disorder with Driving-Related Avoidance
Panic attacks have decreased from six to two per month, and Panic Disorder Severity Scale has improved from 15 to 9. She is progressing through her exposure hierarchy without escape behavior.
3. As-Needed Benzodiazepine Use
Lorazepam before drives is acting as a safety behavior and may slow exposure progress. Hydroxyzine previously helped at daytime doses.
4. Insomnia
Sleep onset is delayed by about an hour from work-related worry.
5. Mild Intermittent Asthma
Beta-blockers for anxiety are avoided given her asthma.
6. Follow Up
Time Documentation
Psychotherapy Start Time: 2:05 PM
Psychotherapy Stop Time: 2:50 PM
Total Psychotherapy Time: 45 minutes, separate from time spent on medication management.
Billing Considerations
Established patient E/M visit at moderate complexity for prescription drug management, with a separately documented 45-minute psychotherapy add-on and diagnosis linkage to generalized anxiety disorder and panic disorder.
Chief Complaint
Adult ADHD evaluation for lifelong inattention, disorganization, and impulsivity affecting work, driving, and relationships.
History of Present Illness (HPI)
Andy Comstock is a 41-year-old male who presents for an adult ADHD evaluation after his 9-year-old son was diagnosed with ADHD in spring 2026 and he recognized similar patterns in himself.
He describes lifelong difficulty sustaining attention in meetings, losing track of tasks halfway through, and missing deadlines, which led to a performance improvement plan at work in August. His wife reports he interrupts conversations and forgets commitments. He has had three speeding tickets in five years. He denies depressed mood, current substance use, or suicidal thoughts. He states, "I've spent my whole life thinking I was just lazy, and watching my son made me wonder."
Primary Concerns and Reason for Evaluation
Diagnostic clarification of adult ADHD and treatment options, prompted by worsening work performance, his son's diagnosis, and strain in his marriage.
Developmental and Childhood History
Born full term without complications. Met developmental milestones on time. No head injuries, seizures, or serious childhood illnesses. His mother describes him as "always on the go," climbing furniture, and unable to sit through family meals. Teachers frequently moved his seat for talking out of turn. He was never evaluated for ADHD.
School and Learning
Elementary report cards from 1992 to 1996 include comments such as "bright but easily distracted" and "rarely finishes classwork." Attended summer school for math in 7th grade. Graduated high school with a 2.6 GPA. Left a 4-year college after three semesters in 2004 due to missed assignments. Completed an associate degree in logistics online in 2010, which took four years.
Occupational History
Has held six jobs over 15 years, most ending due to missed deadlines or boredom. Has worked as a logistics coordinator at his current company for four years. Placed on a performance improvement plan in 08/2026 for late reports and errors in shipment schedules.
Social and Relationship Functioning
Married for 11 years with two children, ages 9 and 6. His wife manages household finances after several late bill payments. Couples counseling in 2024 focused on forgotten commitments and interrupting. Has close friendships but often arrives late to plans.
Collateral Information
Wife (interviewed in person): Reports he loses keys and his phone daily, starts home projects without finishing them, and interrupts others. Describes him as "loving but scattered." Confirms loud snoring and pauses in his breathing at night.
Mother (interviewed by phone): Confirms hyperactivity, impulsivity, and inattention from early elementary school, consistent with his report cards.
Records Reviewed: Elementary report cards from 1992 to 1996, his son's ADHD evaluation from 05/2026, and driving record showing three speeding tickets and two minor rear-end collisions in 2019 and 2023.
Rating Scales and Structured Interview
Adult ADHD Self-Report Scale (ASRS v1.1) Part A: 5 of 6, positive screen.
Wender Utah Rating Scale: 58, above the cutoff of 46, supporting childhood ADHD symptoms.
Conners' Adult ADHD Rating Scales, Self-Report: ADHD Index T-score 72. DSM Inattentive Symptoms T-score 76. DSM Hyperactive-Impulsive Symptoms T-score 69.
Conners' Adult ADHD Rating Scales, Observer (Wife): ADHD Index T-score 75. DSM Inattentive Symptoms T-score 78. DSM Hyperactive-Impulsive Symptoms T-score 71.
Interpretive Summary: Self and observer ratings are consistent and clinically elevated, with inattention most prominent. Agreement between his report and his wife's ratings supports validity.
Diagnostic Interview for ADHD in Adults (DIVA-5):
Inattention, Childhood: 7 of 9 criteria
Inattention, Adulthood: 8 of 9 criteria
Hyperactivity-Impulsivity, Childhood: 8 of 9 criteria
Hyperactivity-Impulsivity, Adulthood: 6 of 9 criteria
Impairment: Present at work, in education, in relationships, in finances, and in driving, in both childhood and adulthood.
Screening for Comorbid Conditions
PHQ-9: 6, mild depressive symptoms related to work stress.
GAD-7: 8, mild anxiety centered on job performance.
Mood Disorder Questionnaire: 2 of 13, negative.
AUDIT-C: 2.
STOP-BANG: 5, high risk for obstructive sleep apnea.
Epworth Sleepiness Scale: 11, mild excessive daytime sleepiness.
Columbia Suicide Severity Rating Scale Screener: Negative.
Psychiatric History
2019: Treated by his primary care physician with escitalopram 10 mg for anxiety. Minimal benefit after 8 months. Discontinued.
2024: Completed 10 sessions of couples counseling.
No psychiatric hospitalizations, suicide attempts, or self-harm.
Behavioral Medication History
Escitalopram (2019): 10 mg daily for 8 months. Minimal benefit. Discontinued.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Hospitalization:
None.
Current Medications
Omeprazole 20 mg daily
Family History
Social History
Education level: Associate degree in logistics.
Religious or Spiritual Involvement: Not religious.
Employment: Logistics coordinator, currently on a performance improvement plan.
Smoking Status: Never smoker. No vaping.
Alcohol use: Two beers on weekends.
Caffeine use: Four to five cups of coffee daily and one energy drink in the afternoon, which he says helps him focus.
Drug use: Daily cannabis from 2004 to 2017, used to "quiet his brain." No use since his son was born. No other drug use.
Abuse History: Denies history of abuse.
Substance Abuse History
Substance of choice: Cannabis.
History: Daily use for 13 years, meeting criteria for cannabis use disorder, now in sustained remission for nine years without treatment. State prescription monitoring program reviewed with no controlled substance prescriptions.
Cardiovascular Screening
BP: 138/86 mmHg
HR: 84 bpm
BMI: 31.2 kg/m²
Neck Circumference: 44 cm
ECG (today): Normal sinus rhythm at 82 bpm. PR 160 ms. QRS 92 ms. QTc 412 ms. No abnormalities.
Cardiac History: No chest pain, palpitations, syncope, or exercise intolerance.
Primary Care Labs (2026): TSH 1.9 uIU/mL. CBC and CMP normal. LDL 138 mg/dL.
Mental Status Exam
Appearance: Casually dressed, well groomed.
Behavior: Cooperative and engaged. Fidgeting with his pen and shifting in his chair throughout. Stood up twice during the interview.
Speech: Normal volume, rapid rate, with frequent tangents that he redirected himself.
Mood: "Frustrated but hopeful."
Affect: Full range and appropriate, with humor.
Thought Process: Circumstantial at times but goal-directed.
Thought Content: Focused on work concerns and his son. No suicidal or homicidal ideation. No delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Lost track of two questions mid-answer. Memory intact.
Insight: Good.
Judgment: Good.
Impulse Control: Mildly impaired, with interrupting during the interview.
Differential Diagnosis
ADHD, combined presentation: Most consistent with symptoms present since early childhood across multiple settings, supported by report cards, collateral history, DIVA-5, and CAARS.
Obstructive sleep apnea: Snoring, witnessed apneas, daytime sleepiness, and a STOP-BANG of 5 may worsen attention but would not explain childhood onset.
Anxiety and depressive disorders: Current mild symptoms are secondary to work stress and began long after ADHD symptoms.
Bipolar disorder: No history of manic or hypomanic episodes. MDQ negative.
Substance-related attention problems: No cannabis use in nine years, with symptoms present before and after use.
Risk Assessment
Risk Factors: Impulsive driving with three tickets and two collisions, job instability, and prior cannabis use disorder.
Protective Factors: Supportive wife, strong motivation for treatment, no suicidal ideation, and sustained remission from cannabis.
Assessment: Low acute risk. Outpatient care is appropriate.
Plan
Andy Comstock is a 41-year-old male with ADHD, combined presentation, meeting criteria in both childhood and adulthood, with impairment at work, while driving, and in his marriage, and with possible untreated obstructive sleep apnea.
1. ADHD, Combined Presentation, Moderate
Diagnosis is supported by childhood onset, report cards, collateral reports from his wife and mother, DIVA-5, and elevated self and observer CAARS scores. Untreated sleep apnea may add to his inattention and should be evaluated before starting a stimulant.
I discussed medication options with him:
He chose lisdexamfetamine once sleep apnea testing is complete.
2. Suspected Obstructive Sleep Apnea
Snoring, witnessed apneas, Epworth of 11, and STOP-BANG of 5 indicate high risk.
3. Cardiovascular Screening Before Stimulant Therapy
ECG is normal. Blood pressure is borderline at 138/86 mmHg, and his father had a heart attack at 52.
4. Cannabis Use Disorder, in Sustained Remission
5. Caffeine Use
High caffeine intake may raise heart rate and blood pressure once a stimulant is started.
6. Driving Safety
7. Follow Up
Chief Complaint
PTSD evaluation for nightmares, hypervigilance, avoidance, and increased drinking related to combat trauma.
History of Present Illness (HPI)
Pete Zimmerman is a 36-year-old male Army combat veteran who presents for a PTSD evaluation, referred by his primary care physician after worsening nightmares, irritability, and drinking over the past year.
He describes nightmares about a 2012 roadside bomb attack four to five nights weekly, startling at sudden noises, and avoiding crowds and fireworks. Symptoms worsened after a close friend from his unit died by suicide in November 2025. He drinks four to six beers most nights to sleep. He reports passing thoughts of not waking up, without intent or plan. He states, "I'm home, but part of me never left that road."
Trauma History
Index Trauma: In 06/2012, during deployment to Afghanistan, his vehicle was struck by a roadside bomb. He briefly lost consciousness, and a close friend in the vehicle was killed. He described the event briefly and chose not to share further details today, which was respected.
Other Combat Exposures: Repeated exposure to firefights and to wounded and killed service members during two deployments between 2010 and 2012.
Childhood: Denies abuse or neglect. Describes a stable home.
Life Events Checklist for DSM-5: Endorses combat exposure, sudden violent death of a close friend, and exposure to serious injury of others.
Primary Concerns and Reason for Evaluation
Diagnostic clarification and treatment for trauma-related symptoms that are straining his marriage, affecting his work as a utility lineman, and increasing his alcohol use.
Psychiatric History
2014: Onset of nightmares and irritability after returning home. Did not seek care.
2016: Honorable discharge from the Army after eight years of service.
2017 to 2019: Heavy drinking with divorce from his first wife in 2019. Experienced passive thoughts of death after the divorce. His primary care physician started sertraline.
2021: Stopped sertraline after partial improvement. Remarried and started work as a utility lineman.
07/2025: Fireworks on July 4 triggered a return of flashbacks and nightmares.
11/2025: A close friend from his unit died by suicide. Drinking and nightmares increased.
06/2026: Primary care restarted sertraline at 50 mg and increased to 100 mg in 08/2026, with minimal benefit so far.
No psychiatric hospitalizations or suicide attempts.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Sertraline (2019 to 2021): Up to 100 mg daily. Partial improvement in irritability. Self-discontinued.
Sertraline (06/2026 to present): Restarted at 50 mg, increased to 100 mg in 08/2026. Minimal benefit after 8 weeks at the current dose.
Zolpidem (2020): 5 mg at bedtime from primary care. Stopped after a night of sleepwalking.
Current Medications
Sertraline 100 mg daily
Ibuprofen 400 mg as needed for back pain
Family History
Family Details (current)
Married since 2021 and lives with his wife and 12-year-old stepdaughter. His wife is supportive and joined the end of today's visit. They have slept in separate rooms since 2025 because he kicks and shouts during nightmares. He worries his irritability is affecting his stepdaughter.
Social History
Education level: High school diploma and lineman apprenticeship.
Military History: U.S. Army infantry from 2008 to 2016, with deployments to Afghanistan in 2010 and 2012. Honorable discharge. Not enrolled in VA health care.
Religious or Spiritual Involvement: Raised Catholic. Stopped attending church after his friend's death.
Employment: Full-time utility lineman. Missed several shifts after heavy drinking nights this year.
Smoking Status: Uses nicotine pouches daily.
Alcohol use: Four to six beers most nights, more on weekends.
Caffeine use: Three energy drinks daily during work shifts.
Drug use: Denies cannabis or other drug use.
Abuse History: Denies history of abuse.
Firearms: Owns a handgun and a hunting rifle stored unlocked in his bedroom closet.
Substance Abuse History
Substance of choice: Alcohol.
History: Heavy drinking from 2017 to 2019, reduced from 2021 to 2024, and increased again since 2025. Uses alcohol to fall asleep and avoid nightmares. Meets 4 DSM-5 criteria for alcohol use disorder, including drinking more than intended, failed efforts to cut down, missed work, and continued use despite marital conflict. No withdrawal symptoms or seizures.
Psychometric Assessment
PTSD Checklist for DSM-5 (PCL-5): 58, well above the cutoff of 33 for probable PTSD.
Intrusions (Cluster B): 17 of 20
Avoidance (Cluster C): 7 of 8
Negative Changes in Mood and Thinking (Cluster D): 18 of 28
Arousal and Reactivity (Cluster E): 16 of 24
Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), Past Month: Total severity score 44. Meets criteria B, C, D, E, F, and G for PTSD. No dissociative subtype.
Interpretive Summary: Severe PTSD with prominent intrusive memories, nightmares, avoidance of reminders, guilt about his friend's death, and hyperarousal.
PHQ-9: 14, moderate depressive symptoms.
GAD-7: 13, moderate anxiety.
Insomnia Severity Index: 20, moderate clinical insomnia.
AUDIT: 14, harmful alcohol use.
Ohio State University TBI Identification Method: Positive for one blast injury with loss of consciousness under 5 minutes.
Montreal Cognitive Assessment: 27 of 30.
Columbia Suicide Severity Rating Scale Screener: Positive for wish to be dead in the past month. Negative for active ideation, method, intent, plan, or past behavior.
Mental Status Exam
Appearance: Muscular male in work clothes, appears tired, adequately groomed.
Behavior: Cooperative. Sat facing the door. Startled when a door closed in the hallway. Limited eye contact when discussing his friend.
Speech: Normal rate, low volume, terse answers about the trauma.
Mood: "On edge all the time."
Affect: Constricted and guarded, tearful briefly when discussing his friend's death.
Thought Process: Linear and goal-directed.
Thought Content: Survivor guilt and self-blame about the 2012 attack. Passive death wish without intent or plan. No homicidal ideation. No delusions.
Perceptual Disturbances: Intrusive images of the blast during the day. No hallucinations.
Cognition: Alert and oriented. Attention mildly reduced. Memory intact.
Insight: Fair to good. Recognizes alcohol is worsening his symptoms.
Judgment: Fair, given drinking and unsecured firearms.
Impulse Control: Fair, with reported irritability and verbal outbursts at home.
Differential Diagnosis
Posttraumatic stress disorder, chronic: Most consistent with exposure to a life-threatening event, symptoms in all four clusters for over 10 years, and PCL-5 and CAPS-5 results.
Major depressive disorder: Moderate depressive symptoms overlap with PTSD Cluster D and will be monitored.
Alcohol use disorder, moderate: Meets 4 criteria, with drinking used to manage nightmares and sleep.
Prolonged grief disorder: Grief over his friend's suicide is significant but occurs within the broader PTSD picture.
Persistent post-concussive symptoms: Mild TBI in 2012 with normal cognitive screening today, making it an unlikely primary cause.
Risk Assessment
Risk Factors: Male veteran, severe PTSD, passive death wish, friend's recent suicide, alcohol use disorder, unsecured firearms, and insomnia.
Protective Factors: Supportive wife, responsibility to his stepdaughter, stable employment, no prior attempts, and willingness to engage in treatment.
Assessment: Moderate chronic risk with low acute risk. Outpatient care is appropriate with close follow-up.
Safety Plan: Completed today with warning signs, coping strategies, and contacts, including the Veterans Crisis Line (dial 988, then press 1). He agreed to have his brother store both firearms at his home until his next visit, and his wife will confirm the transfer.
Plan
Pete Zimmerman is a 36-year-old male combat veteran with severe chronic PTSD, worsened by a friend's suicide and complicated by moderate alcohol use disorder, insomnia, and unsecured firearms.
1. Posttraumatic Stress Disorder, Chronic, Severe
PCL-5 of 58 and CAPS-5 severity of 44 confirm severe PTSD across all clusters. He has had minimal benefit from sertraline 100 mg and has never received trauma-focused therapy, which is the first-line treatment.
2. Trauma-Related Nightmares and Insomnia
Nightmares occur four to five nights weekly and drive his evening drinking.
3. Alcohol Use Disorder, Moderate
He drinks four to six beers most nights to sleep, with missed work and marital conflict. He has no opioid use, and liver function is normal.
4. Suicide Risk
Passive death wish since his friend's suicide, with unsecured firearms at home.
5. Veteran Resources and Peer Support
He is not enrolled in VA health care.
6. History of Mild Traumatic Brain Injury and Tinnitus
MoCA is 27 with no current cognitive concerns.
7. Follow Up
Chief Complaint
Three-month medication management visit for bipolar I disorder, with review of lithium level, kidney function, and calcium.
History of Present Illness (HPI)
Steve Gibson is a 46-year-old male with bipolar I disorder, stable on lithium since 2016, who presents for a three-month medication management visit and review of kidney and parathyroid labs.
He reports stable mood since a brief period of reduced sleep in May, with daily mood app ratings in the normal range for the past 90 days. He sleeps seven hours nightly and is working full time. He notes urinating often, a fine hand tremor when typing, and mild fatigue. He denies depressed mood, racing thoughts, or impulsive spending. He states, "Lithium gave me my life back, so I'm nervous about anything that means changing it."
Psychotherapy Summary
We spent 20 minutes reviewing his relapse prevention plan with his wife present. He identified his earliest warning signs from past episodes: sleeping under six hours for two nights, starting several new projects at once, and talking faster on the phone. His wife added that he becomes unusually generous with money.
We reviewed what happened in May, when he slept five hours a night for six days during a busy work period. He recognized the pattern early, used his rescue plan, and called the clinic, which prevented a full episode. We discussed how his lab results may lead to treatment changes over time and that any change would be gradual and shared. He was reassured, stating, "As long as we're watching it together, I can handle that."
Mood Episode Timeline
2001: First manic episode at age 21 with grandiosity, no sleep for four days, heavy spending, and psychotic features. Hospitalized for 10 days. Diagnosed with bipolar I disorder. Started olanzapine and valproate.
2003: Major depressive episode after stopping medications on his own. Treated as an outpatient.
2006: Second manic episode with psychotic features after stopping medications. Hospitalized for 8 days. Restarted valproate with quetiapine.
2006 to 2015: Fewer episodes but ongoing weight gain of 14 kg and prediabetes.
2016: Transitioned to lithium for stronger relapse prevention and fewer metabolic effects. Valproate tapered off, and quetiapine stopped in 2017.
2019: Moderate depressive episode. Lamotrigine added, with remission by 2020.
05/2026: Six days of reduced sleep and increased goal-directed activity during a high-stress period at work. Did not meet full criteria for hypomania. Resolved with a short course of quetiapine at bedtime.
No hospitalizations since 2006.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
Previous Psychiatric or Mental Health Hospitalization:
Behavioral Medication History
Olanzapine (2001 to 2006): 15 mg nightly. Effective for mania. Discontinued for 12 kg weight gain.
Valproate (2001 to 2016): Up to 1500 mg daily. Partial prevention of episodes. Weight gain and hair thinning.
Quetiapine (2006 to 2017): Up to 300 mg nightly. Effective for sleep and mood. Discontinued for sedation and prediabetes.
Lithium carbonate (2016 to present): 1200 mg daily from 2016 to 2024, reduced to 900 mg extended-release at bedtime in 2024 for declining kidney function. Highly effective, with no hospitalizations since starting.
Lamotrigine (2019 to present): Titrated to 200 mg daily. Effective for depressive episodes. No rash.
Quetiapine (05/2026): 50 mg at bedtime for one week as a rescue medication. Effective.
Current Medications
Lithium carbonate extended-release 900 mg at bedtime
Lamotrigine 200 mg daily
Levothyroxine 75 mcg daily
Atorvastatin 10 mg nightly
Quetiapine 50 mg at bedtime as needed per rescue plan
Family History
Family Details (current)
Married for 15 years and lives with his wife and two teenage sons. His wife is closely involved in his care and attended today's visit. She tracks his sleep with him and knows his rescue plan.
Social History
Education level: Bachelor's degree in business.
Religious or Spiritual Involvement: Attends a Lutheran church with his family.
Employment: Full-time regional sales manager.
Smoking Status: Never smoker.
Alcohol use: Rarely, a few times per year.
Caffeine use: One cup of coffee in the morning, none after noon.
Drug use: Denies cannabis or other drug use.
Abuse History: Denies history of abuse.
Firearms: No firearms in the home.
Substance Abuse History
Substance of choice: None.
History: No history of substance use disorder.
Mood Charting Summary
Daily mood app ratings from the past 90 days show 84 days in the normal range, 6 days of mild elevation in May, and no days of low mood lasting more than two consecutive days. Average sleep from his wearable device is 7.1 hours nightly over the past 30 days.
Psychometric Scores
Young Mania Rating Scale: 3, no current manic symptoms.
Quick Inventory of Depressive Symptomatology (QIDS-SR16): 4, no depression.
PHQ-9: 3.
Columbia Suicide Severity Rating Scale Screener: Negative.
Vitals
BP: 128/80 mmHg
HR: 66 bpm
Weight: 92 kg (90 kg in 2025)
BMI: 29.1 kg/m²
Medication Monitoring Labs
Lithium Level, 12-Hour Trough:
Kidney Function (eGFR in mL/min/1.73 m²):
Urine Albumin-to-Creatinine Ratio (10/2026): 18 mg/g
Calcium and Parathyroid Hormone:
Thyroid Function (10/2026): TSH 2.4 uIU/mL, free T4 1.2 ng/dL on levothyroxine.
Metabolic Labs (10/2026): HbA1c 5.8%. LDL 128 mg/dL. Triglycerides 180 mg/dL.
Mental Status Exam
Appearance: Well groomed in business casual clothing.
Behavior: Cooperative, calm, with good eye contact. Fine tremor of both hands when holding his phone.
Speech: Normal rate, rhythm, and volume.
Mood: "Steady."
Affect: Euthymic, full range, and appropriate.
Thought Process: Linear and goal-directed.
Thought Content: Focused on lab results and work. No grandiosity. No suicidal or homicidal ideation. No delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Attention and memory intact.
Insight: Excellent. Knows his warning signs and rescue plan.
Judgment: Good.
Impulse Control: Good.
Risk Assessment
Risk Factors: Bipolar I disorder with prior psychotic mania and a family history of suicide.
Protective Factors: Ten years of stability on lithium, strong insight, engaged spouse, stable employment, no substance use, and no firearms in the home.
Assessment: Low acute risk. Outpatient care is appropriate.
Plan
Steve Gibson is a 46-year-old male with bipolar I disorder who has been stable on lithium for ten years, now with slowly declining kidney function and new hypercalcemia linked to lithium.
1. Bipolar I Disorder, Most Recent Episode Hypomanic, in Partial Remission
He is euthymic with a YMRS of 3 and QIDS of 4, and his brief period of reduced sleep in May was managed early without a full episode. Lithium has prevented hospitalization for ten years after two prior manic episodes with psychosis.
2. Chronic Kidney Disease Stage 3a Associated with Lithium
eGFR has declined from 98 to 58 over ten years, with a slower decline since the 2024 dose reduction. Albuminuria is minimal. I discussed continuing lithium at a lower level against switching to other mood stabilizers, which carry higher relapse risk for him. He chose to continue lithium with closer monitoring.
3. Hypercalcemia with Elevated Parathyroid Hormone
Calcium has risen to 10.7 mg/dL with a parathyroid hormone of 88 pg/mL, consistent with lithium-associated hyperparathyroidism.
4. Lithium-Induced Hypothyroidism
TSH is 2.4 uIU/mL on levothyroxine.
5. Lithium-Related Polyuria and Tremor
He urinates about 2.5 liters daily and wakes twice at night. A fine postural tremor affects typing.
6. Metabolic Monitoring
LDL is 128 mg/dL and HbA1c is 5.8%, with a 2 kg weight gain this year.
7. Relapse Prevention Plan
8. Follow Up
Chief Complaint
Geriatric psychiatry evaluation of agitation, nighttime wandering, and delusions of theft in moderate Alzheimer's dementia.
History of Present Illness (HPI)
Addison Hurley is a 79-year-old female with moderate Alzheimer's dementia who presents with her daughter for a geriatric psychiatry evaluation of agitation, nighttime wandering, and accusations of theft that have escalated since July 2026.
Her daughter reports she accuses family of stealing her purse daily, becomes combative during evening baths, and has tried to leave the house at 2 AM twice. Lorazepam started at urgent care in August was followed by a fall and more confusion. Addison says her knees hurt when she walks. She denies feeling sad or seeing things that others do not. She states, "Someone keeps moving my things, and nobody believes me."
Caregiver Report
Daughter (primary caregiver, interviewed separately): Behaviors cluster between 4:00 PM and 9:00 PM. Accusations of theft occur when Addison cannot find her purse, which she hides in different places each day. Agitation is worst during evening baths, when she has pushed her daughter twice. She paces the hallway after dinner and tries the front door at night. Episodes ease with her favorite 1950s music and looking at family photos. The daughter reports exhaustion and feeling "like a stranger in my mother's eyes."
Behavior Triggers Identified:
Behavioral Symptom History
2020: Repeating questions and misplacing items. Noticed by her husband.
2022: Neurology evaluation with MoCA 21 of 30, MRI showing hippocampal atrophy, and a positive amyloid PET. Diagnosed with mild Alzheimer's dementia. Donepezil started.
2023: Stopped driving after getting lost in her own neighborhood. Husband died that year.
2024: Moved in with her daughter. MoCA 16 of 30. Memantine added.
2025: Began accusing family of moving or taking belongings. Evening restlessness started.
07/2026: Agitation escalated during evening baths. Tried to leave the house at night twice.
08/2026: Urgent care prescribed lorazepam 0.5 mg at bedtime. Fell in the bathroom one week later without fracture. Daughter noticed more daytime confusion.
09/2026: Neurology referred her to geriatric psychiatry.
Psychiatric History
No psychiatric diagnoses or treatment before dementia. No history of depression, psychosis, hospitalization, or suicide attempts.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
None before this evaluation.
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Donepezil (2022 to present): 10 mg nightly. Tolerated without GI side effects.
Memantine (2024 to present): 10 mg twice daily. Tolerated.
Lorazepam (08/2026 to present): 0.5 mg at bedtime from urgent care. Followed by a fall and increased confusion.
Current Medications
Donepezil 10 mg nightly
Memantine 10 mg twice daily
Lorazepam 0.5 mg at bedtime
Amlodipine 5 mg daily
Alendronate 70 mg weekly
Calcium carbonate 600 mg with vitamin D3 800 IU daily
Family History
Family Details (current)
Widowed since 2023. Lives with her daughter, her daughter's husband, and their teenage son in a two-story home. Her daughter works part time from home and is her durable power of attorney and health care proxy. Her son lives out of state and calls weekly.
Social History
Education level: High school diploma.
Religious or Spiritual Involvement: Lifelong Baptist. Enjoys hymns and attending church with her daughter.
Employment: Retired school cafeteria manager.
Smoking Status: Never smoker.
Alcohol use: None.
Caffeine use: One cup of coffee in the morning.
Drug use: None.
Abuse History: No concerns for abuse or neglect identified on caregiver and patient interview.
Firearms: No firearms in the home.
Driving: Stopped driving in 2023.
Substance Abuse History
Substance of choice: None.
History: No history of substance use.
Functional Status
Activities of Daily Living: Needs help choosing clothes and full assistance with bathing. Feeds herself and toilets independently with occasional nighttime accidents.
Instrumental Activities of Daily Living: Dependent for medications, finances, cooking, shopping, and transportation.
Psychometric and Cognitive Assessment
Montreal Cognitive Assessment: 21 of 30 (2022), 16 of 30 (2024), 11 of 30 (today).
Functional Assessment Staging Tool (FAST): Stage 5, moderate dementia.
Neuropsychiatric Inventory Questionnaire (NPI-Q): Severity 16 and caregiver distress 22. Highest in nighttime behaviors, agitation, delusions, and aberrant motor behavior.
Cohen-Mansfield Agitation Inventory: 62, with physically non-aggressive behaviors such as pacing and trying to leave, along with verbal agitation.
Cornell Scale for Depression in Dementia: 9, mild depressive symptoms with irritability and poor sleep.
Pain Assessment in Advanced Dementia (PAINAD): 0 at rest, 4 while walking.
Zarit Burden Interview (daughter): 24, high caregiver burden.
Interpretive Summary: Moderate Alzheimer's dementia with significant agitation, delusions of theft, and sleep disruption clustered in the evening, with untreated pain and benzodiazepine use as likely contributors.
Medical Workup
Labs (09/2026): CBC and CMP within normal limits. Sodium 138 mmol/L. TSH 2.1 uIU/mL. Vitamin B12 520 pg/mL. Urinalysis negative for infection.
ECG (today): Normal sinus rhythm. QTc 432 ms.
MRI Brain (2022): Bilateral hippocampal atrophy. Mild small vessel changes.
Amyloid PET (2022): Positive for cortical amyloid deposition.
Mental Status Exam
Appearance: Neatly dressed with help from her daughter. Appears her stated age.
Behavior: Pleasant and engaged early in the visit. Became restless after 30 minutes and asked twice where her purse was.
Speech: Fluent with word-finding pauses. Normal rate and volume.
Mood: "Fine, just tired of people taking my things."
Affect: Mildly irritable, brightening when discussing her grandson.
Thought Process: Tangential at times, redirectable.
Thought Content: Fixed belief that family members take her belongings. No suicidal or homicidal ideation.
Perceptual Disturbances: No hallucinations reported or observed.
Cognition: Oriented to person only. Could not recall any of three words. Impaired attention and executive function.
Insight: Poor. Does not recognize memory loss.
Judgment: Impaired.
Impulse Control: Mildly impaired in the evening per caregiver report.
Decision-Making Capacity
She could not describe her medications or weigh treatment options and does not have capacity for complex medical decisions. She was able to express preferences, including wanting to stay home with her daughter and hear her music. Her daughter, as health care proxy, participated in all decisions today.
Differential Diagnosis
Agitation and psychosis due to Alzheimer's dementia: Most consistent with evening-predominant agitation, delusions of theft linked to misplacing items, and progression with cognitive decline.
Delirium: Less likely with normal labs, negative urinalysis, and no acute change in attention outside the evening, although lorazepam may have added confusion.
Dementia with Lewy bodies: Less likely without visual hallucinations, parkinsonism, or REM sleep behavior.
Depression in dementia: Mild symptoms on the Cornell Scale, which may add to irritability.
Pain-related agitation: Likely contributor, with PAINAD of 4 while walking.
Risk Assessment
Risk Factors: Nighttime wandering with door-seeking, recent fall on lorazepam, physical aggression during bathing, and high caregiver burden.
Protective Factors: Devoted family caregivers, no firearms in the home, no prior self-harm, and response to music and familiar routines.
Assessment: Moderate risk for wandering and falls. Low risk of harm to self or others with a safety plan in place.
Plan
Addison Hurley is a 79-year-old female with moderate Alzheimer's dementia and evening agitation, delusions of theft, and wandering, with untreated knee pain and recent lorazepam use as likely contributors.
1. Agitation and Delusions of Theft in Alzheimer's Dementia
Behaviors follow predictable evening triggers, and non-drug strategies are first-line. A low-dose antidepressant may help agitation and mild depressive symptoms with lower risk than antipsychotics.
2. Lorazepam Use
Lorazepam is linked to her recent fall and worsened confusion.
3. Knee Osteoarthritis Pain
PAINAD rises to 4 with walking, and pain likely worsens evening restlessness.
4. Sleep Disruption and Sundowning
5. Wandering and Home Safety
6. Caregiver Burden
Her daughter's Zarit score of 24 indicates high burden.
7. Cognitive Medications
8. Advance Care Planning
Her daughter is a health care proxy and durable power of attorney.
9. Follow Up
Chief Complaint
Evaluation for opioid use disorder and buprenorphine initiation after a nonfatal fentanyl overdose.
History of Present Illness (HPI)
Joel Moore is a 31-year-old male with opioid use disorder who presents for evaluation and buprenorphine treatment after a nonfatal fentanyl overdose in August 2026, his second since 2022.
He smokes about 1 gram of fentanyl daily and last used 18 hours ago. He reports chills, aching legs, a runny nose, and restlessness that began this morning. He also uses cannabis nightly and smokes a pack of cigarettes daily. He denies alcohol, stimulant, or benzodiazepine use and denies suicidal thoughts. His sister drove him today. He states, "I woke up on the bathroom floor with my sister crying, and I'm done living like this."
Psychotherapy Summary
We used motivational interviewing to explore what brought him in today. He described the August overdose as a turning point, especially seeing his sister's fear. He rated his readiness to stop fentanyl as 9 out of 10 and his confidence as 6 out of 10, citing past relapse after leaving methadone.
We explored what helped during his six months on methadone in 2023, including daily structure and steady work, and what led to dropout, mainly a clinic schedule that conflicted with his job. He identified office-based buprenorphine as a better fit. We discussed what to expect during induction, and he chose to start today. He said, "If I can work and still get treatment, I can actually stick with it."
Substance Use History
2017: L4-L5 disc herniation from a warehouse injury. Prescribed oxycodone 10 mg four times daily by his primary care physician for 18 months.
2019: Oxycodone stopped abruptly when his prescriber retired. Began buying oxycodone pills from friends.
2021: Switched to counterfeit pills containing fentanyl, then to smoking fentanyl powder.
03/2022: First overdose. Revived with naloxone by a friend and treated in the emergency department.
2023: Enrolled in a methadone program for six months, stabilized on 80 mg daily. Left the program due to a schedule conflict with work and relapsed within two weeks.
2023: Positive hepatitis C antibody and RNA during methadone intake. Not treated.
2024 to 2026: Daily fentanyl use, increasing to about 1 gram per day.
08/2026: Second overdose. His sister gave two doses of nasal naloxone before EMS arrived. Discharged from the emergency department with a naloxone kit and referral to this clinic.
Current Use Pattern
Fentanyl: About 1 gram daily, smoked. Last use 18 hours ago.
Cannabis: Smoked nightly for sleep, about 1 gram.
Nicotine: One pack of cigarettes daily since age 16.
Alcohol: Denies use since 2021.
Stimulants: Denies use. Tried cocaine twice in 2015.
Benzodiazepines: Denies use.
Injection Drug Use: Injected heroin and fentanyl from 2021 to 2022. Denies injection since. Reports no needle sharing since 2022.
DSM-5 Criteria for Opioid Use Disorder
Larger amounts or longer than intended: Met
Persistent desire or failed efforts to cut down: Met
Great deal of time obtaining, using, or recovering: Met
Craving: Met
Failure to fulfill major role obligations: Met
Continued use despite social problems: Met
Important activities given up: Met
Recurrent use in physically hazardous situations: Met
Continued use despite physical or psychological problems: Met
Tolerance: Not counted, as initial use was under medical supervision
Withdrawal: Not counted, as initial use was under medical supervision
Total: 9 of 11 criteria met, consistent with severe opioid use disorder.
Psychiatric History
Depressive symptoms since 2019. Never formally diagnosed or treated. No psychiatric hospitalizations. Both overdoses were unintentional, which he and his sister confirm. No history of suicide attempts or self-harm.
Past Medical History (PMH)
Illness, Injuries, Operations and Treatments:
Previous Psychiatric or Mental Health Treatment:
Previous Psychiatric or Mental Health Hospitalization:
None.
Behavioral Medication History
Oxycodone (2017 to 2019): 10 mg four times daily for back pain. Stopped abruptly.
Methadone (2023): Titrated to 80 mg daily. Effective for cravings. Left treatment after six months.
Buprenorphine: Never prescribed.
Current Medications
Ibuprofen 400 mg as needed for back pain
Naloxone 4 mg nasal spray, from the emergency department
Family History
Family Details (current)
Lives with his older sister and her two young children since 08/2026. His sister is supportive and attended the second half of today's visit. Single, with no children. His brother has offered to be a recovery support.
Social History
Education level: High school diploma.
Religious or Spiritual Involvement: Not religious.
Employment: Works part time at an auto repair shop. Lost his warehouse job in 2024 due to missed shifts.
Housing: Stable with his sister.
Insurance: Medicaid.
Transportation: No car. Relies on his sister and Medicaid transportation.
Smoking Status: One pack of cigarettes daily.
Alcohol use: None since 2021.
Caffeine use: Two energy drinks daily.
Abuse History: Denies history of abuse.
Legal: No current legal issues.
Withdrawal Assessment
Clinical Opiate Withdrawal Scale (COWS):
10:00 AM: 11, mild withdrawal, with sweating, restlessness, runny nose, and bone aches
11:30 AM: 14, moderate withdrawal, with added yawning and gooseflesh
12:30 PM: 7, after first buprenorphine dose
1:30 PM: 3, after second buprenorphine dose
Labs and Monitoring
Point-of-Care Urine Drug Screen (today): Positive for fentanyl and cannabinoids. Negative for buprenorphine, methadone, oxycodone, morphine, cocaine, amphetamines, and benzodiazepines. Confirmatory testing sent.
Prescription Drug Monitoring Program (today): No controlled substance prescriptions since 2019.
Hepatitis C (2023): Antibody positive. RNA 1.2 million IU/mL, genotype 1a.
Hepatitis B (2023): Surface antigen negative. Surface antibody negative, not immune.
HIV (2023): Negative.
Comprehensive Metabolic Panel (08/2026): AST 49 U/L (high). ALT 58 U/L (high). Albumin 4.1 g/dL. Bilirubin 0.8 mg/dL.
CBC (08/2026): Within normal limits. Platelets 212 x 10^3/μL.
Psychometric Scores
PHQ-9: 12, moderate depressive symptoms.
GAD-7: 10, moderate anxiety.
AUDIT-C: 0.
Columbia Suicide Severity Rating Scale Screener: Negative.
Mental Status Exam
Appearance: Thin male in a hooded sweatshirt, mildly diaphoretic.
Behavior: Cooperative but restless, shifting in his seat and yawning often.
Speech: Normal rate and volume.
Mood: "Sick and nervous."
Affect: Anxious, congruent, with appropriate tearfulness when discussing his sister.
Thought Process: Linear and goal-directed.
Thought Content: Focused on withdrawal and starting treatment. No suicidal or homicidal ideation. No delusions.
Perceptual Disturbances: No hallucinations.
Cognition: Alert and oriented. Attention mildly reduced due to withdrawal.
Insight: Good. Recognizes the danger of fentanyl and the need for treatment.
Judgment: Improving, as shown by seeking care.
Impulse Control: Fair.
Differential Diagnosis
Opioid use disorder, severe: Meets 9 of 11 DSM-5 criteria, with two overdoses.
Opioid withdrawal: Confirmed by rising COWS scores 18 hours after last fentanyl use.
Cannabis use disorder, mild: Nightly use for sleep, to be assessed further.
Tobacco use disorder: Daily cigarette use since adolescence.
Major depressive disorder: Moderate symptoms that may be substance-related, to be reassessed after four weeks of stability.
Risk Assessment
Risk Factors: Recent fentanyl overdose, ongoing daily fentanyl use, prior injection use, reduced tolerance after treatment interruptions, and depressive symptoms.
Protective Factors: Strong motivation, supportive sister and brother, stable housing, part-time work, and prior response to opioid agonist treatment.
Assessment: High risk of accidental overdose. Low risk of intentional self-harm.
Plan
Joel Moore is a 31-year-old male with severe opioid use disorder from fentanyl, with two nonfatal overdoses, who started buprenorphine in clinic today after reaching moderate withdrawal.
1. Opioid Use Disorder, Severe, Fentanyl
He reached a COWS of 14 at 11:30 AM, allowing safe initiation without precipitated withdrawal. Buprenorphine was chosen over methadone to fit his work schedule.
2. Overdose Prevention and Harm Reduction
3. Chronic Hepatitis C
Untreated since 2023, with mildly elevated liver enzymes.
4. Infectious Disease Prevention
5. Tobacco Use Disorder
6. Depressive and Anxiety Symptoms
7. Chronic Low Back Pain
8. Follow Up
NEW PATIENT
New Patient Evaluatio
Establishes the patient’s psychiatric history, current symptoms, and mental status for the initial evaluation
WHAT MARVIX AI CAPTURES
Captures
HPI, mental status exam, psychiatric history, prior treatments
Coding
New-patient E/M level with MDM rationale
Also generates
Diagnostic workup orders and referral letters
MED MANAGEMENT
Medication Management
Reviews medication response and treatment tolerance to guide ongoing management.
WHAT MARVIX AI CAPTURES
Captures
Dosage changes, adherence, side effects, symptom response
Coding
Established-patient E/M level with MDM rationale
Also generates
Updated medication plan and AVS
PSYCHOTHERAPY
Psychotherapy Session
Documents therapeutic interventions and patient response across therapy modalities.
WHAT MARVIX AI CAPTURES
Captures
Therapy modality, session content, patient response, coping mechanisms
Coding
E/M and psychotherapy add-on coding
Also generates
Treatment plan and session summary
RISK ASSESSMENT
Risk Assessment
Documents safety evaluation and risk factors to guide crisis planning.
WHAT MARVIX AI CAPTURES
Captures
Suicidality, safety plan, risk factors, protective factors
Coding
E/M level with MDM rationale and risk flagging
Also generates
Safety plan and follow-up orders
CONSULT-LIAISON
Consult-Liaison Visit
Supports psychiatric consultation for patients admitted under other specialties.
WHAT MARVIX AI CAPTURES
Captures
Referral reason, mental status exam, recommendations
Coding
Consult-appropriate E/M level
Also generates
Consultation note and referral summary
CHILD & ADOLESCENT
Child & Adolescent Visit
Documents developmental history and family context alongside psychiatric symptoms.
WHAT MARVIX AI CAPTURES
Captures
Developmental history, family input, school functioning, symptoms
Coding
Age-appropriate E/M level with MDM rationale
Also generates
Treatment plan and caregiver instructions
OCD
OCD Evaluation
Documents obsessions, compulsions, and functional impact to guide treatment.
WHAT MARVIX AI CAPTURES
Captures
Obsession and compulsion detail, symptom severity, functional impact
Coding
ICD-10 with severity specified
Also generates
Treatment plan and therapy referral
TELEPSYCHIATRY
Telepsychiatry Visit
Supports remote psychiatric care while maintaining documentation continuity across visits.
WHAT MARVIX AI CAPTURES
Captures
Interval symptom status, medication response, risk factors
Coding
Telehealth-appropriate E/M level
Also generates
Treatment plan and AVS?
CRISIS
Crisis Visit
Documents acute presentation and safety planning for urgent psychiatric evaluation.
WHAT MARVIX AI CAPTURES
Captures
Acute symptoms, risk assessment, disposition planning
Coding
ER/urgent-visit E/M level with MDM rationale
Also generates
Disposition summary and safety plan
PROCEDURE
In-Office Procedure
Documents botulinum toxin, nerve blocks, and EMG/NCS studies with consent and technique detail.
WHAT MARVIX AI CAPTURES
Captures
Indication, consent, sites, dosing and technique
Coding
Procedure CPT with units and modifiers
Also generates
Post-procedure instructions and AVS
Generic scribes
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Marvix AI
Psychiatry-Specific Templates
General-purpose templates
Built for psychiatric conditions and therapy modalities, with condition- and therapy-specific templates
Mental Status Exam & Scores
Manual capture, inconsistent scoring
Structures all MSE domains and auto-embeds PHQ-9, GAD-7, MMPI scores with interpretive summaries
Medication Regimen Tracking
Manual documentation
Logs current and discontinued medications, dosage changes, adherence, and side effects across the treatment timeline
Symptom & Mood Histories
Standardized note output
Builds time-anchored summaries of mood episodes and behavioral patterns across visits
Long, Complex Consults
Limited context handling
Designed for detailed psychiatric visits up to 90+ minutes
Composite Notes
Manual chart review
Carries forward histories, assessments, and medication regimens from prior visits
Medical Billing & Coding
Manual chart review
ICD-10, CPT, and E/M coding with MDM rationale, modifiers, HCC, and risk flagging
Payer Compliance
Not addressed
Medical-necessity language and audit-ready documentation built in
Pre-Visit Preparation
Manual chart review / limited support
AI-generated Patient Recap summaries
Provider-Personalized Notes
Standardized note output
Learns your documentation style
Team Collaboration
Limited support
Physicians, MAs, NPs & nurses collaborate in one note
AI Assistant
Not available
Chat with every consult using transcripts, notes & uploaded files
EHR Integration
Varies by platform
Deep two-way integration with major EHRs
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*overages charged at $3/hour after exceeding the plan limit
**Group discounts available
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*overages charged at $3/hour after exceeding the plan limit
**Group discounts available
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