CM MACROS | Health And Willness

CM Provider Macros

ADHD

HPIs

 Patient name, DOB, and address verified and confirmed to be located in a state in which the provider is licensed. 

The patient gives verbal consent to receive healthcare services via video for this encounter.  The patient was informed that video visits are performed using real-time telehealth tools, including a live video connection and sometimes an in-person visit may be needed to fully evaluate them.
__________________________________________________________________________________________

h/o Dx:
PCP:
AWE:

Patient responded NO to a history of bipolar, psychosis, schizophrenia, suicidal attempts or mental hospitalization.

_____ here for ADHD symptoms.

General symptoms: The patient reports that 

Give EXAMPLES of how this has affected you in… 

--Childhood:

--Relationships:

--Work:

Other histories:
-- history of depression? [Review PHQ9] Reviewed, denies history
-- history of anxiety? [Review GAD7], Reviewed, denies history
-- History of other psychiatric diagnoses or psychiatric hospitalizations? None
-- Current therapist? None
-- Current illicit drug use? None
 
PDMP reviewed on ____ in PA/NY/NJ:

At their initial visit, it was determined that the patient had symptoms suggestive of ADHD.

See the last encounter chart note for details.

ASRS PART B
-Please use questions to get more details about symptoms-
Choose one of the following that describes how you have felt or conducted yourself over the last 6 mos: 
- Never 1
- Rarely 2
- Sometimes 3
- Often 4
- Very often 5

7. How often do you make careless mistakes when you have to work on a boring or difficult project?  (>often)
8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?  (>often)
9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? (>sometimes)
10. How often do you misplace or have difficulty finding things at home or at work?  (>often)
11. How often are you distracted by activity or noise around you?  (>often)
12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? (>sometimes)
13. How often do you feel restless or fidgety?  (>often)
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?  (>often)
15. How often do you find yourself talking too much when you are in social situations?  (>often)
16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves? (>sometimes)
17. How often do you have difficulty waiting your turn in situations when turn-taking is required?  (>often)
18. How often do you interrupt others when they are busy? (>sometimes)

PDMP reviewed: yes, see previous note  

The DSM-5 was references to make the diagnosis. The patient exhibits the following symptoms consistent with ADHD:
INATTENTIVE SYMPTOMS:
√ Lack of attention to detail
√ difficulty sustaining attention
√ Doesn't listen well when spoken to
√ Lack of follow through on tasks
√ Difficulty organizing
√ Avoids/dislikes starting tasks that require sustained mental effort
√ Loses things
√ Distractible by extraneous stimuli
√ Forgetful

HYPERACTIVE/IMPULSIVE SYMPTOMS
√ Fidgety
√ Restless
√ Can't stay quiet during leisure/activies
√ Drive by a motor
√ Talks excessively
√ Blurts out answers/thoughts
√ Difficulty waiting turn
√ Interrupts others when busy
 
COMBINED:
Assessment reveals significant patterns at home/school/work that interfere with self-confidence and interpersonal relationships with colleagues, family, and friends. Pt displays impairment at focusing, organization, and time management. This causes distress in their social and occupational functioning. Given the history, presentation of symptoms, and assessment scores, the patient appears to have ADHD, combined type, which is affecting their physical and mental health, interrupts day-to-day life, reduces daily productivity, affects focus, and affects patientʼs overall quality of life.

Patient has five or more symptoms of inattention and ≥5 symptoms of hyperactivity/impulsivity that have persisted for ≥6 months to a degree that is inconsistent with the developmental level and negatively impacts social and occupational activities. 

Several symptoms (inattentive and hyperactive/impulsive) were present before the age of 12 years, and several symptoms (inattentive and hyperactive/impulsive) have been present in ≥2 settings. There is clear evidence that the symptoms interfere and have interfered with or reduced the quality of social, academic, and occupational function. 

Discussed with the patient options for treatment including stimulants (generic adderall and ritalin), Strattera, and Wellbutrin. Discussed pros and cons of each medication, as well as what side effects to expect. Shared decision-making was used to trial generic stimulants for symptom management as needed.    

INATTENTIVE:
Assessment reveals significant patterns at home/school/work that interfere with self-confidence and interpersonal relationships with colleagues, family, and friends. Pt displays impairment at focusing, organization, and time management. This causes distress in their social and occupational functioning. Given the history, presentation of symptoms, and assessment scores, the patient appears to have ADHD, predominantly inattentive type, which is affecting their physical and mental health, interrupts day-to-day life, reduces daily productivity, affects focus, and affects the patientʼs overall quality of life. 
 
Patient has five or more symptoms of inattention that have persisted for ≥6 months to a degree that is inconsistent with the developmental level and negatively impacts social and occupational activities. 

Several ADHD symptoms were present before the age of 12 years, and several symptoms have been present in ≥2 settings. There is clear evidence that the symptoms interfere and have interfered with or reduced the quality of social, academic, and occupational function.

 Patient name, DOB, and address verified and confirmed to be located in a state in which the provider is licensed. 

The patient gives verbal consent to receive healthcare services via video for this encounter.  The patient was informed that video visits are performed using real-time telehealth tools, including a live video connection and sometimes an in-person visit may be needed to fully evaluate them.
__________________________________________________________________________________________

___________ here for an ADHD follow-up visit and medication refill. 

ADHD HISTORY
-- Current medication: Adderall 5mg BID
-- Duration on this dose: ____
-- Duration of Effect:
-- Drug holidays: 
-- How long on this medication: since ____
—> 🏥 In-person Appt: ___
—> 🧾 AWE: ___

How does the medication improve your life?  
√ 
√ 
√ 

Are there things about it that you do not like?
• Denies any side effects

Have you considered a lower dose or taking days off from the medication? Skips days as above

-- Specific side effects:
Sleep? No issues
Appetite? No issues
Weight change? No change
Mood change? Stable, no change

Last BP: 
LMP: 

-- Target symptoms not being addressed: All being addressed as above
-- Past meds: None
-- Current therapist: No

PDMP reviewed on ____ in PA/NY/NJ:

 Patient name, DOB, and address verified and confirmed to be located in a state in which the provider is licensed. 

The patient gives verbal consent to receive healthcare services via video for this encounter.  The patient was informed that video visits are performed using real-time telehealth tools, including a live video connection and sometimes an in-person visit may be needed to fully evaluate them.
__________________________________________________________________________________________

Patient responded ___ to (ADHD with a history of bipolar, psychosis, schizophrenia, suicidal attempts or mental hospitalization):

_________ here to establish care for their ADHD.

EXISTING DX, NEW TO PRACTICE
ADHD HISTORY
-- General symptoms:

-- First diagnosed:
-- Name of physician/practice and location: 
-- Last in-office visit?

-- Early symptoms in grade school:
-- Family/ relationship issues:
-- Target symptoms:
-- Medication now:
-- How long on this medication:
-- Past meds (name, strength, date, and duration tried needed for PA):

-- Current issues with sleep, appetite, weight?
-- Current therapist?
-- history of depression?
-- history of anxiety?
-- Current / past illicit drug use? No

PDMP reviewed on ____ in PA/NY/NJ:

PLANS

We discussed your symptoms may be consistent with ADHD.

----------NO PCP----------
To establish care with Circle Medical, you need to have had an annual physical within the last 12 months. You have not had this done, so we scheduled our next appointment as a Virtual Wellness exam. It is strongly recommended you complete the following prior to the second appointment:
- blood pressure check
- weight
- a copy of immunizations

I have booked you a follow-up appointment on _______________ to further discuss your symptoms. 
----------------------------------------
OR
----------HAD AWE----------
To establish care with Circle Medical, you need to have had an annual physical within the last 12 months.  We discussed that you have had an annual physical within the last 12 months. 

We discussed you obtaining the visit note from your last annual checkup which was within the last 12 months, and emailing them to records@circlemedical.com.  Receipt of records is required prior to the second appointment.  I will be unable to prescribe any controlled substance medications without documentation of an annual physical. If we need to send an official medical records request to receive them directly from the facility, please let me know. 

I have booked you a follow up appointment on _______ to further discuss your symptoms. 
----------------------------------------
OR
----------WANTS LOCAL PCP----------
To establish care with Circle Medical, you need to have had an annual physical within the last 12 months.  We discussed that you have not had an annual physical. 

You would like to find a new local PCP to have your annual physical done at. You are going to make an appointment with a new PCP. We will conduct your next visit ot finalize your ADHD after this visit is complete, and we will need medical records verifying this. You should be able to obtain the visit note after your appointment, and you can email this to records@cirlcemedical.com. I will be unable to prescribe any controlled substance medications without documentation of an annual physical. 

WE did discuss that if you don't have luck finding a local PCP, we can offer PCP services through telemedicine, and we can conduct the annual physical online at your next appointment. This will remain an option for you. 

I have sent you an appointment reminder to book with me after your PCP appointment. This will trigger in 2 weeks. 
----------------------------------------
ADHD EDUCATION:
ADHD is highly manageable with an individualized, multimodal treatment approach that can include behavioral interventions, parent/patient training, educational support, and medication.  Although medication is a very useful tool for controlling your symptoms, the best chance of success comes from the use of cognitive behavioral modification, education, and a generalized awareness of how your ADHD affects almost every aspect of your life.  Take the time to learn about your diagnosis.  Go to the links provided and read about ADHD, and the myriad different techniques and steps commonly used for the management of symptoms.

Other ways to improve your focus and attention: 
• Sleep at least 7 hours every night, with a consistent bedtime, even on weekends. 
• Walk outside during the day for at least 30 minutes daily (ideally elevating heart rate).
• Digital detox. Limit smartphone use. 
• Eat a healthy diet with lots of Omega 3s
• Avoid boredom through Flow. Throughout the day, focus on specific challenges in the moment that lead to engagement in the present. 
• CBT—therapy with a specialist in ADHD

ADHD HELPFUL LINKS
- www.Rena-fi.org
- www.ADD.org
- www.CHADD.org
- www.additudemag.com

We discussed your symptoms are consistent with ADHD. We decided a trial of generic Adderall to treat your symptoms is warranted.

Treatment goals for you are: improved focus, completing tasks, staying organized, focusing on conversations, and better time management.

Medication name/ dose/ number dispensed/ refills: 
Dextroamphetamine-amphetamine 5mg, take 1 tab by mouth in AM and early afternoon, #30, 0 refills

Please review the educational PDF here: https://tinyurl.com/ycy8c7kx

This medication can be taken as needed.  The onset is usually within 30 minutes.  Be sure to drink plenty of water throughout the day and try to have a full breakfast prior to your first dose.  Side effects may include palpitations, insomnia, reduction in appetite, or weight loss. 

It's recommended to take "drug holidays", meaning you should try to skip taking your medications at least once per week. This often works out best on the weekends. It helps prevent your body from building up a tolerance, and helps the medication work better when you do take it. 

If after 1 week you feel like the 5mg isn't working well in the morning, you can try taking 2 tablets (10mg total) in the morning to see how you feel. You should have extra pills to do this if you skip medications on certain days like the weekend.

This is a controlled substance, and you have signed a controlled substance agreement. We have given you a 2-week supply, and have scheduled a 2-week follow up, where we will assess your response to the medication. We may need to increase the dose at that time. We will meet monthly afterwards to evaluate your response and renew your prescription. 

Your insurance may require a Prior Auth in order to cover the medications.  This can take several days. While the team works on your prior auth, consider using GoodRx to find pharmacies offering the best discounted cash pay rate.
https://www.goodrx.com/amphetamine-salt-combo?slug=amphetamine-salt-combo&form=tablet&dosage=5mg&quantity=28&label_override=amphetamine-salt-combo

Please feel free to reach out via the CM app if you have any questions or concerns.

We discussed your symptoms are consistent with ADHD. We decided a trial of generic stimulant to treat your symptoms is warranted. 

Treatment goals for you are: improved focus, completing tasks, staying organized, focusing on conversations, and better time management.

Medication name/ dose/ number dispensed/ refills: 
- Methylphenidate 10mg, Take 1 tab PO in AM and 1 tab PO in afternoon PRN for ADHD, #30, 0 refills

This medication can be taken as needed.  The onset is usually within 30 minutes.  Be sure to drink plenty of water throughout the day and try to have a full breakfast prior to your first dose.  Side effects may include palpitations, insomnia, reduction in appetite, or weight loss. 

It's recommended to take "drug holidays", meaning you should try to skip taking your medications at least once per week. This often works out best on the weekends. It helps prevent your body from building up a tolerance and helps the medication work better when you do take it. 

This is a controlled substance, and you have signed a controlled substance agreement. We have given you a 2-week supply, and have scheduled a 2-week follow-up, where we will assess your response to the medication. We may need to increase the dose at that time. We will meet monthly afterward to evaluate your response and renew your prescription. 

Consider using GoodRx to find pharmacies offering the best-discounted cash pay rate.
https://www.goodrx.com/methylphenidate?form=tablet&dosage=10mg&quantity=30&label_override=methylphenidate

Please feel free to reach out via the CM app if you have any questions or concerns.

We discussed your symptoms are consistent with ADHD. We decided a trial of stimulants to treat your symptoms is warranted - we decided on Vyvanse.

Treatment goals for you are: improved focus, completing tasks, staying organized, focusing on conversations, and better time management.

Medication name/ dose/ number dispensed/ refills: 
- Vyvanse 30mg, Take 1 capsule PO in AM PRN for ADHD, #15, 0 refils
(PO means by mouth, PRN means as needed)

Vyvanse is a prescription medication that is used to treat attention deficit hyperactivity disorder (ADHD) in adults and children. It belongs to a class of medications called central nervous system (CNS) stimulants, which work by increasing the levels of certain chemicals in the brain that are responsible for controlling impulse control and hyperactivity.

Vyvanse is taken ONCE daily in the morning, with or without food. Swallow the capsule whole and do not crush, chew, or open it. This medication should last all day, about 10-12 hours.

Some common side effects of Vyvanse include loss of appetite, weight loss, trouble sleeping, and dizziness. These effects may go away as your body adjusts to the medication. 

However, there are some side effects that are serious and require immediate medical attention. These include chest pain, rapid heartbeat, hallucinations, agitation, aggressive behavior, and difficulty breathing. If you experience any of these side effects, go to the emergency room immediately.

It's recommended to take "drug holidays", meaning you should try to skip taking your medications at least once per week. This often works out best on the weekends. It helps prevent your body from building up a tolerance and helps the medication work better when you do take it. 

This is a controlled substance, and you have signed a controlled substance agreement. We have given you a 2-week supply, and have scheduled a 2-week follow-up, where we will assess your response to the medication. We may need to increase the dose at that time. We will meet monthly afterward to evaluate your response and renew your prescription. 

We did discuss the stock shortage with ADHD medications as well, as well as the fact that your insurance may not approve of Vyvanse. If not, we discussed some backups:
- Adderall 5mg BID #28 (big stock issues though)
- Dextroamphetamine 5mg BID #28

We discussed both of these medications and how they differ from Vyvanse, their side effects, and what to expect. 

Please feel free to reach out via the CM app if you have any questions or concerns.

We discussed your current prescription dosage and agreed to keep you on the same regimen of stimulants that you've been taking. 

I have sent the following prescription to your preferred pharmacy and it will be available for pickup in the next 24 -48 hrs:
Rx: 

I have sent this to your preferred pharmacy on file. Please contact your pharmacy directly to inquire when your prescriptions can be filled. Strict regulations allow controlled medications to be filled when the last prescription course is close to completion. Circle Medical policy does not allow for replacement or early prescriptions. Exceptions are made on a case-by-case basis and reasoning needs to be reviewed during a visit.  

We have scheduled an appointment with your Provider for 4 weeks. An appointment reminder has been sent to you.

We discussed your current prescription dosage and agreed to make some changes based on your continued symptoms.

I have sent the following prescription to your preferred pharmacy and it will be available for pick up in the next 24 -48 hrs:
Rx: 

I have sent this to your preferred pharmacy on file. Please contact your pharmacy directly to inquire when your prescriptions can be filled. Strict regulations allow controlled medications to be filled when the last prescription course is close to completion. Circle Medical policy does not allow for replacement or early prescriptions. Exceptions are made on a case by case basis and reasoning needs to be reviewed during a visit.  

We have scheduled an appointment with your Provider for 2 weeks. An appointment reminder has been sent to you.

NJ-Specific

 ____ - please send your FULL VISIT NOTE from your last yearly checkup with your PCP to records@circlemedical.com. Alternatively, you can take screenshots of the full note and attach them to this chat thread directly! Remember we will need this before you can be prescribed medications at our next visit!

We discussed your ADHD and agreed you would benefit from stimulant therapy. We have you set up with an in-person Provider in our Short Hills office this Friday. This in-person visit is required before stimulants can be started in NJ, and is required in-person every 3 months. You will follow with the Provider you see in-person online afterwards. I will be in the Short Hills office at the end of May if you would like to see me in-person then. 
Short Hills office instructions: https://drive.google.com/file/d/1INJ4DNbFrIOhvoiXoiJVXzY5SxwXdh6Z/view?usp=sharing

We discussed your symptoms are consistent with ADHD. We agreed that trialing a stimulant would be the most beneficial for you at this time. 

Treatment goals for you are: improved focus, completing tasks, staying organized, focusing on conversations, and better time management.

Due to NJ state law, we cannot start this medication until you are seen in-person FIRST, and then seen every 3 months. You will also need to see whoever you see in person online afterwards for your refills of schedule-II medications like stimulants.

We scheduled you with my colleague _____ at ____ EST, who will review your chart and discuss treatment options with you.

The Marlton Office Address:
5 Greentree Centre
Suite 117
Marlton, NJ 08053

The directions don't always work out by putting the address in your navigation, so below are pins which should take you to the correct location regardless
Apple Maps: https://tinyurl.com/4ubm9855
Google Maps: https://tinyurl.com/2trfcpy5

Use this PDF for additional instructions: https://drive.google.com/file/d/1hcbV-j2yrp2k1ZWzrj1wKL3pGFrb6F_P/view?usp=sharing

Updated Short Hills Office Instructions:
830 Morris Turnpike, 4th Floor
Short Hills, NJ 07078

Once you enter the building you will walk straight to the elevator. The elevator will be on your right when entering from the front and to your left if entering from the back parking lot. Take the elevator to the 4th floor. Once on the 4th floor, go to your right, you will see a sign for Regus. Turn right and you will see the doors to Regus down the hall. 

There should be a QR code for you to scan, or a front desk person to check you in!

PDF with additional Info: https://drive.google.com/file/d/1vaq5t24kVY8Xp62vgrk8WgAer59Xq2iR/view?usp=sharing

NYC Office Address:
156 William St, Suite 303
New York, NY 10038

PDF INSTRUCTIONAL: https://drive.google.com/file/d/15vQF3xqy-nyGe9u056-h18a0oMPyp8GP/view?usp=drive_link

ROS/PE/PDMP

General: As above, otherwise feeling well, no fever, no chills, no night sweats
Eyes: No vision change, no eye pain
HENMT: No new headaches, no hearing changes, no rhinorrhea, no dysphagia, no sore throat
CV: No chest pain, no palpitations, no syncope, no edema
Resp/Pulm: No shortness of breath, no wheezing, no cough
Neuro: No new headaches, no paresthesias
Psych: No mood changes, focus as per HPI
Skin: No rashes, no skin changes

General: Well appearing, no acute distress
Head: Normal facies, no deformity, no obvious ecchymosis or abrasions
Eyes: Anicteric sclera, symmetric pupils, no exophthalmos
Ears/Nose/Mouth/Throat: Hearing is grossly normal. Quality of speech normal.
Respiratory/Lungs: Able to complete full sentences. No tachypnea or respiratory distress was noted. No coughing during the visit.
MSK: Moving upper extremities spontaneously, appears grossly normal
Neuro: Alert and oriented. CN II-XII grossly intact
Psych: Normal judgment, insight, and mood; appropriate affect
Skin: no rashes, no ecchymoses, no suspicious lesions

ANNUAL WELLNESS

HPI/PLAN

 Patient name, DOB, and address verified and confirmed to be located in a state in which the provider is licensed. 

The patient gives verbal consent to receive healthcare services via video for this encounter.  The patient was informed that video visits are performed using real-time telehealth tools, including a live video connection and sometimes an in-person visit may be needed to fully evaluate them.
__________________________________________________________________________________________

-ANNUAL WELLNESS EXAM-
  
- Last AWE: 
- History of last blood work completed: 
- History of lab abnormalities:

SPECIALISTS:
OBGYN: 
Dermatology: 
Other: 

SLEEP HEALTH
How long?: 
Issues?: 
Snore?: 

MENTAL HEALTH
Anxiety: Reviewed GAD7, 
Depression: Reviewed PHQ9, 

PREVENTATIVE HEALTH
--VISION EXAM: 
--DENTAL EXAM: 
--MAMMO:

-------------------------------------------------------------------------------------------------------
Today we conducted an annual wellness exam where we discussed your overall health. We ask that you do the following in order to maximize your overall health and stay up to date on your screenings:

1. We ordered lab work for you to get drawn at a local Labcorp. The order form has been sent to the chat, and the staff at Lab Corp may want to see this when you present to get drawn. You will need to fast for at least 8 hours before getting it drawn, and provide a urine sample. Most Lab-Corps accept walk-ins.
You can find a local Lab Corp here: https://www.labcorp.com/precheck

We ordered the following labs: 
- CBC to check for anemia
- CMP & Magnesium to check your electrolytes, kidneys, glucose, and liver
- Lipids to check for cholesterol
- STI testing including HIV, Syphilis, Gonorrhea, and Chlamydia 

2. 

3. 

4. 

5. 

General recommendations to address preventative health:
__Routine eye and dental appointments.  Let us know if you need help finding a provider.
—Drink at least 64oz of water daily (caffeinated drinks do not count)
—Regular physical exercise:
*Aim for at least 30 minutes of moderate activity (e.g., jogging, cycling, swimming) 5 times per week (or at least 150 minutes total per week) or 75 minutes total per week of vigorous activity (e.g., running). 
*Link to specific guidelines: https://www.cdc.gov/physicalactivity/basics/adults/index.htm 
—A balanced diet rich in whole fruits/vegetables:
*Aim for at least 2 servings of fruit and 3 servings of veggies per day. 
*An easy rule of thumb is 1/2 plate should contain veggies, 1/4 protein, 1/4 complex carbohydrates.
*Avoid processed or fried/fatty foods, fast foods, and soda. 
*Be mindful of your sugar intake and alcohol/caffeine in moderation.
—Avoid smoking tobacco of any kind
—Get at least 20 minutes of sunlight daily to increase Vitamin D levels
—Wear sunscreen!  Apply SPF 30 to your face and exposed skin every day to prevent the cumulative effects of UV rays which can lead to skin cancer.
—Stay up-to-date on your immunizations.  Get your seasonal flu shot every year as well as appropriate CDC vaccinations for your age group
—Practice good Sleep Hygiene.  Your brain and body need rest.  Sometimes certain symptoms are related to your lifestyle and not an underlying medical condition.  I recommend checking out this site for tips:
https://www.sleepfoundation.org/articles/sleep-hygiene

ROUTINE CANCER SCREENINGS:
--Cervical Cancer Screening: NA
--Breast Cancer Screening: NA
--Colon Cancer Screening: Screen at age 45
--Skin Cancer Screening: Screen every 3 years between ages 20-40, annually after age 40
--Prostate Cancer Screening: Screen at age 55, age 40 if first-degree relative, 2 extended-degree relatives, or AA.
--Lung Cancer Screening: NA (Screened annually between 50-80 with 20 Pack-year history and currently smoke/quit within last 15 years)
--Osteoporosis Screening: NA

ROUTINE CANCER SCREENINGS:
--Cervical Cancer Screening: Screening due ____ (Screen 21-29 every 3 years with PAP; 30-65 get Pap + HPV every 5 years)
--Breast Cancer Screening: Screen at age 40-45
--Colon Cancer Screening: Screen at age 45
--Skin Cancer Screening: Screen every 3 years between ages 20-40, annually after age 40
--Prostate Cancer Screening: NA
--Lung Cancer Screening: NA (Screened annually between 50-80 with 20 Pack-year history and currently smoke/quit within last 15 years)
--Osteoporosis Screening: NA (Screen at age 65 in women, post-menopausal if increased risk)

Screenings Due

We discussed that you are overdue for a dental appointment and/or cleaning. This is recommended to have a cleaning every 6 months, and a full dental evaluation at least every 12 months. Please schedule an appointment with a local dentist. You can find more information here: https://findadentist.ada.org/

You are due for an eye examination. This is recommended every 5-10 years in healthy people ages 18-40, and every 2-4 years ages 40-54. Those who wear contacts or glasses should have one annually. Please make an appointment with an optometrist or ophthalmologist local to you.

You are overdue for a pap smear. This is recommended to be done every 3 years starting at age 21. This is when a sample of your cervix is sent to a lab to detect any precancerous lesions. Lesions often take years to turn into cancer, so it is essential to get these done when recommended to prevent long-term complications. Please make an appointment with your OBGYN for this to be done. If you do not have an OBGYN, you can search online or on your health insurance portal - you should NOT require a referral for an OBGYN, but if you do please let me know.

You are overdue for a pap smear. This is recommended to be done every 3 years starting at age 21. This is when a sample of your cervix is sent to a lab to detect any precancerous lesions. Lesions often take years to turn into cancer, so it is essential to get these done when recommended to prevent long-term complications. Please make an appointment with your OBGYN for this to be done. If you do not have an OBGYN, you can search online or on your health insurance portal - you should NOT require a referral for an OBGYN, but if you do please let me know. 

To find LGBT friendly OBGYNs, I like to use the following resources:
 • https://www.outcarehealth.org/outlist/
• https://www.healthgrades.com/ and look up the specialty "Bisexual And Transgender Gynecology"

 I recommend scheduling an appointment with a dermatologist for a full body evaluation, as this is recommended once every 3 years between age 20-40, and annually after. This is to help recognize moles or skin lesions that are precancerous or cancerous, or lesions to watch closely.

Screenings Due

We discussed your blood pressure, and we need this checked every 3-6 months while on stimulants, or at least yearly in patients not on stimulants. Please check this at a local pharmacy, grocery store, or with a cuff. If you do not have a cuff, you can buy one on Amazon here: https://tinyurl.com/5x9wrr7d
Once you check this, please send me your reading over the chat, or take a picture/write it down so we can go over it at next visit.

Please check your records to see when your last tetanus was given. This should be updated every 10 years, or 5 years if you get a contaminated cut. If it is outdated, you can get this updated at your local pharmacy without a doctors order. You can find more info about this vaccine here: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/dtap.html

We discussed a mammogram and I am going to order one. I placed the order, but it can take a few days for you to hear more information in the chat, once our team speaks with your insurance company and figures out where you can get it done. Mammogram screenings are a crucial part of breast cancer prevention and early detection. The general recommendation is for women to begin regular mammograms at the age of 40, with annual screenings until at least the age of 54. After 55, they may opt for screenings every two years, depending on their health status and doctor's advice. However, these guidelines can vary based on individual risk factors. Women with a family history of breast cancer or genetic predispositions, like BRCA mutations, may need to start screenings earlier or have more frequent mammograms.

We've discussed the importance of a colonoscopy, and I'll be sending a referral to a GI specialist to do this for you. The order is in place, but it might take a few days for further details to be available in the chat. Colonoscopies play a vital role in the prevention and early detection of colorectal cancer. It's generally recommended that individuals start regular colonoscopies at the age of 45, with screenings typically occurring every 10 years.

MED Rx

Adderall

- Amph-dextroamph (Adderall) __ mg, Take 1 tab PO in AM and 1 tab PO in afternoon PRN for ADHD, #60, 0 refills

- Amph-dextroamph (Adderall) Er __ mg, Take 1 capsule PO in AM PRN for ADHD, #30, 0 refills

- Amph-dextroamph (Adderall) Er __ mg, Take 1 capsule PO in AM PRN for ADHD, #30, 0 refills
- Amph-dextroamph (Adderall) Ir __ mg, Take 1 tab PO in afternoon PRN for ADHD, #30, 0 refills

- Amph-dextroamph (Adderall) Ir __ mg, Take 1 tab PO in afternoon PRN for ADHD, #30, 0 refills

- Amph-dextroamph (Adderall) __ mg, Take 1 tab PO every 3-4 hours up to 3 times daily PRN for ADHD, #90, 0 refills

Vyvanse

- Vyvanse 30 mg, Take 1 capsule PO in AM PRN for ADHD, #15, 0 refills

- Vyvanse 30 mg, Take 1 capsule PO in AM PRN for ADHD, #30, 0 refills

Ritalin

- Methylphenidate (Ritalin) __ mg, Take 1 tab PO in AM and 1 tab PO in afternoon PRN for ADHD, #60, 0 refills

- Methylphenidate Er (Ritalin LA) __ mg, Take 1 capsule PO in AM PRN for ADHD, #30, 0 refills

- Concerta __ mg, Take 1 capsule PO in AM PRN for ADHD, #30, 0 refills

- Methylphenidate Er (Ritalin LA) __ mg, Take 1 capsule PO in AM PRN for ADHD, #30, 0 refills
- Methylphenidate (Ritalin) __ mg, Take 1 tab PO in afternoon PRN for ADHD, #30, 0 refills

- Methylphenidate (Ritalin) __ mg, Take 1 tab PO every 3-4 hours up to 3 times daily PRN for ADHD, #90, 0 refills

MISC / CHAT

No Shows

Hello _____. You missed your appointment at ___. It is now ____ and I am logging of zoom. Please book an appointment with me at your earliest convenience. If my schedule is too booked out, please book an appointment with one of my colleagues if needed. Thanks!

Hello _____. You missed your appointment at ___. It is now ____ and I am logging of zoom. Please book an appointment with me or one of my colleagues in the app if you still need a medical evaluation. Thanks and have a good day!

Labs

CHOLESTEROL HIGH ON LABS
Your cholesterol is a little high. Your Total cholesterol was ___, and we like that below 200. Your LDL (bad cholesterol) was ___, which we like below 100. Your HDL was ___, which we like above 40. Your triglycerides were ___, which we like below 150. To improve your cholesterol panel, I recommend decreasing fatty fried foods, processed carbs, and increase green leafy vegetables, healthy fats like olive or avocado oil, and those found in nuts. Increasing exercise can also improve cholesterol.

MISC

_______ - We did discuss the annual wellness requirement that we need to have on file in order to send your prescription.  You are going to call your doctor's office to try and get this or find it on your online portal. We are looking for the FULL VISIT NOTE of your last annual wellness exam (also may be called annual physical or yearly physical). We need the full visit note and not just the visit summary. If you're able to get ahold of this, please send it to Records@circlemedical.com.

Please respond here whenever you do get those and send them, and I will review them and then send your prescription!

I sent a medical records request. This should come to your email within the next 1-2 days for you to sign, so we can get records from your previous provider. You will need to sign this within 72 hours so the link does not expire. Once signed, our team will fax over the medical request to your doctor’s office and send you a message in the app. To speed this along, you can always call after this verification to help facilitate the records.

Please send any medical records or lab results you have to records@circlemedical.com so it can be attached to your chart.

 As we discussed during our last visit, I recommended continuing with your psychiatrist, or finding a second opinion if you aren't happy with your ADHD management.

Circle Medical is a primary care practice that delivers care via telemedicine.  We truly want patients to receive the safest and most comprehensive care for your individual needs.  Unfortunately, due to your Bipolar disorder, as well as your chronic opioids and benzo medications, your mental health care is best suited for a local, in-office psychiatrist and not a telemedicine platform. 

If you need to find a new mental health care provider, I recommend looking on the back of your insurance card and calling the phone number for mental health services. You can also use the following website and search for "psychiatrist" by zip code and insurance plan. https://www.psychologytoday.com/us

I also recommend utilizing the following search engines to find specialists, which can find doctors in your area who take your insurance:
- Zocdoc.com
- Healthgrades.com

Thank you in advance for your understanding.

MEDucation

ADHD Meds

VYVANSE MEDICATION INFORMATION: 
Vyvanse is a prescription medication that is used to treat attention deficit hyperactivity disorder (ADHD) in adults and children. It belongs to a class of medications called central nervous system (CNS) stimulants, which work by increasing the levels of certain chemicals in the brain that are responsible for controlling impulse control and hyperactivity.

Vyvanse is taken ONCE daily in the morning, with or without food. Swallow the capsule whole and do not crush, chew, or open it. This medication should last all day, about 10-12 hours.

Some common side effects of Vyvanse include loss of appetite, weight loss, trouble sleeping, and dizziness. These effects may go away as your body adjusts to the medication. 

However, there are some side effects that are serious and require immediate medical attention. These include chest pain, rapid heartbeat, hallucinations, agitation, aggressive behavior, and difficulty breathing. If you experience any of these side effects, go to the emergency room immediately.

It's recommended to take "drug holidays", meaning you should try to skip taking your medications at least once per week. This often works out best on the weekends. It helps prevent your body from building up a tolerance and helps the medication work better when you do take it. 

This is a controlled substance, and you have signed a controlled substance agreement. We have given you a 2-week supply, and have scheduled a 2-week follow-up, where we will assess your response to the medication. We may need to increase the dose at that time. We will meet monthly afterward to evaluate your response and renew your prescription.

WELLBUTRIN (BUPROPION) INFORMATION:

Wellbutrin, with the active ingredient bupropion, is primarily used to treat major depressive disorder (MDD) and seasonal affective disorder (SAD), but can also be helpful for ADHD. It is an antidepressant belonging to the class of drugs known as norepinephrine-dopamine reuptake inhibitors (NDRI). Unlike typical antidepressants, Wellbutrin works by increasing the levels of norepinephrine and dopamine in the brain, which helps to improve mood and reduce feelings of depression.

Wellbutrin XL is usually taken once a day, in the morning, with or without food. It's important to swallow the tablet whole and not to crush, chew, or break it, as this medication is designed to release slowly in the body. Consistent daily intake at the same time each day is recommended for optimal effectiveness. If a dose is missed, take it as soon as possible, but if it's near the time for the next dose, skip the missed dose. Do not take two doses at once.

Common side effects include dry mouth, nausea, insomnia, dizziness, sore throat, muscle pain, sweating, ringing in the ears, and fast heartbeat. Most of these side effects may decrease as your body adjusts to the medication. However, if they persist or worsen, consult your doctor.

Serious side effects, though rare, should not be ignored. These include seizures, confusion, hallucinations, irregular heartbeat, severe muscle pain, fever, and rash. If you experience any of these symptoms, seek medical attention immediately.

Avoid alcohol while taking Wellbutrin, as it can increase the risk of seizures. It is also important to inform your doctor about any other medications you are taking, as Wellbutrin can interact with various drugs.

In conjunction with medication, engaging in regular physical activity, maintaining a balanced diet, and practicing stress-reduction techniques can support overall mental health and well-being.

STRATTERA MEDICATION INFORMATION:
Strattera (atomoxetine) is a medication prescribed for the treatment of Attention Deficit Hyperactivity Disorder (ADHD). Here's some important patient education information regarding its use:

Dosage and Administration: Strattera can be taken with or without food. The capsules should not be crushed, chewed, opened, or broken but swallowed whole. It's usually prescribed either once daily in the morning or in divided doses in the morning and late afternoon/early evening. Dosage often starts low and may be adjusted depending on efficacy and tolerance.

Side Effects: Common side effects in children and teenagers may include upset stomach, decreased appetite, nausea or vomiting, dizziness, tiredness, and mood swings. Adults might experience constipation, dry mouth, decreased appetite, dizziness, sexual side effects, and difficulty urinating. Strattera can also affect growth rate in children, so height should be monitored during treatment.

Warnings and Precautions: Strattera can increase heart rate and blood pressure, so it should be used cautiously in individuals with heart conditions or high blood pressure. It may also cause orthostatic hypotension (a drop in blood pressure upon standing). Rarely, it can precipitate manic or psychotic symptoms, especially in people with undiagnosed bipolar disorder. Strattera is not advised within two weeks of taking MAO inhibitors due to the risk of severe reactions.

Pregnancy and Breastfeeding: Strattera's safety during pregnancy and breastfeeding is not well-established. Therefore, it should only be used if the potential benefits justify the risks.

Missed Dose and Overdose: If a dose is missed, it should be taken as soon as remembered but skipped if it's almost time for the next dose.

Anxiety/Depression

BUSPIRONE INFORMATION:

Buspirone is a medication primarily used to treat generalized anxiety disorder (GAD). It is classified as an anxiolytic and works differently from typical sedatives like benzodiazepines. Buspirone acts on serotonin and dopamine receptors in the brain, which helps to reduce anxiety without causing significant sedation or dependence.

Buspirone is typically taken orally, and the dosage and frequency will be determined by your doctor based on your condition. It is usually taken two to three times a day and should be taken consistently, either always with or always without food. Consistency in taking the medication is important for its effectiveness. If you miss a dose, take it as soon as you remember, but if it's close to the time of your next dose, skip the missed dose. Never double up on doses.

Common side effects of Buspirone include dizziness, headache, nausea, nervousness, lightheadedness, and excitement. These side effects are usually mild and tend to decrease over time as your body adjusts to the medication. However, if they persist or worsen, it is advisable to consult your doctor.

Serious side effects are rare but require immediate medical attention. These include symptoms of an allergic reaction (such as rash, itching/swelling, severe dizziness, trouble breathing), unusual changes in mood or behavior, and uncontrollable movements of the arms and legs.

It is important to avoid consuming large amounts of grapefruit or grapefruit juice while taking Buspirone, as grapefruit can increase the likelihood of side effects. Also, avoid alcohol and other central nervous system depressants while on this medication, as they can enhance drowsiness and dizziness.

Engaging in relaxation techniques like deep breathing, meditation, and regular physical activity can complement the effectiveness of Buspirone in managing anxiety. Maintaining a balanced diet and ensuring adequate sleep are also beneficial.

Always follow your doctor's instructions regarding medication usage, and do not adjust your dose without consulting them. Regular follow-up appointments are important to monitor the medication's effectiveness and make any necessary adjustments.

MIRTAZEPINE DRUG INFORMATION:
Mirtazapine is an antidepressant that is used to treat major depressive disorder and can be used for other conditions as determined by your doctor, including anxiety disorders.

Take Mirtazapine orally, usually once a day at bedtime, as its sedative effects can assist with sleep. Mirtazapine can be taken with or without food.
While Taking Mirtazapine alcohol, or driving and operating heavy machinery. 

Be aware of common side effects like drowsiness, increased appetite, weight gain, dry mouth, and dizziness. Report any severe or unusual side effects to your doctor, including mood changes, agitation, or suicidal thoughts.

If you miss a dose of Mirtazapine, take it as soon as you remember. However, if it is near the time of your next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Do not suddenly stop taking Mirtazapine without talking to your doctor, as this can cause withdrawal symptoms. Your doctor will guide you on how to gradually decrease the dose.

LISINOPRIL INFORMATION:
Lisinopril is a medication commonly used to treat high blood pressure (hypertension) and heart failure. It's also prescribed to improve survival after a heart attack. Lisinopril belongs to a class of drugs known as ACE inhibitors (Angiotensin-Converting Enzyme inhibitors). It works by relaxing blood vessels, which lowers blood pressure and improves blood flow. This helps to reduce the workload on the heart.

It's important to take Lisinopril exactly as prescribed by your doctor. Typically, it's taken once a day, with or without food. Consistency in the time of day you take the medication is key for effectiveness. If you miss a dose, take it as soon as you remember, but skip the missed dose if it's almost time for your next dose.

Common side effects include cough, dizziness, headache, extreme tiredness, nausea, diarrhea, weakness, sneezing, runny nose, low sex drive, and rash. If you experience any severe side effects like swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, difficulty breathing or swallowing, hoarseness, or fainting, seek medical attention immediately.

Avoid potassium supplements or salt substitutes containing potassium without consulting your doctor.

Adopting a healthy lifestyle can enhance the effectiveness of Lisinopril. This includes maintaining a balanced diet, regular exercise, avoiding smoking, and limiting alcohol consumption.

SSRI DRUG INFORMATION:

Fluoxetine is in a class of medications called Selective Serotonin Re-uptake Inhibitors. These increase serotonin levels in the brain to help treat anxiety and depression.

The medication is taken every day and is non-addictive. It does need to be taken every day, and usually does not help much with anxiety or depression for 4-6 weeks to take full effect. I recommend trying this medication for at least 6 months to see if it helps.

There are few side effects, which many get better with continued use. Common side effects include dizziness, upset stomach, or headaches. All SSRIs have the potential to decrease sexual interest or cause some erectile dysfunction. If this happens, please let me know.

If you develop any suicidal thoughts or severe anxiety or depression, please stop taking your medication and reach out to your family, go to a local ER, or call the national crisis line at 1-800-273-TALK (8255), OR text ‘TALK’ to 741741 to speak to trained counselors.

Propranolol is a medication that is used primarily for the heart, but low doses have been effective for helping with anxiety as well.

This is usually taken as needed, at least 30-60 minutes before an anxiety-provoking event.

Low doses are less likely to experience side effects, but possible side effects include fatigue, bad dreams, and a slow heart rate. It can cause an inhaler to not work as well for those with a history of asthma. It can also mask symptoms of hypoglycemia in patients who are prone to this (usually patients on diabetic medications).

If you become dizzy or experience chest pain or pass out, please seek emergent care at a local ER.

OTHER

LISINOPRIL INFORMATION:
Lisinopril is a medication commonly used to treat high blood pressure (hypertension) and heart failure. It's also prescribed to improve survival after a heart attack. Lisinopril belongs to a class of drugs known as ACE inhibitors (Angiotensin-Converting Enzyme inhibitors). It works by relaxing blood vessels, which lowers blood pressure and improves blood flow. This helps to reduce the workload on the heart.

It's important to take Lisinopril exactly as prescribed by your doctor. Typically, it's taken once a day, with or without food. Consistency in the time of day you take the medication is key for effectiveness. If you miss a dose, take it as soon as you remember, but skip the missed dose if it's almost time for your next dose.

Common side effects include cough, dizziness, headache, extreme tiredness, nausea, diarrhea, weakness, sneezing, runny nose, low sex drive, and rash. If you experience any severe side effects like swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs, difficulty breathing or swallowing, hoarseness, or fainting, seek medical attention immediately.

Avoid potassium supplements or salt substitutes containing potassium without consulting your doctor.

Adopting a healthy lifestyle can enhance the effectiveness of Lisinopril. This includes maintaining a balanced diet, regular exercise, avoiding smoking, and limiting alcohol consumption.

WEIGHT LOSS

HPI

______ is a _______ here for weight consultation visit #1.

Current Height:
Current Weight:
Current BMI: 

WEIGHT JOURNEY
- Highest Adult Weight: 
- Lowest Adult Weight:
- Motivation: 
- Support System: 
- Previous Weight Loss Attempts: 
- Weight loss attempts? (weight loss programs [WW, Noom, etc], previous bariatric surgery, Rx medications)
- Last 6 months: 
- Previous Meds: 

FOOD HABITS
- Typical Meals: 
- Snacks:
- Eating Out: 
- Ordering in: 
- Beverages:
- Water intake:

SLEEPING HABITS
- Hours: 
- Trouble falling asleep: 
- Frequently waking up: 
- Snoring: 

ACTIVITY HABITS
- Steps/day: 
- Formal Exercise:

ANNUAL HISTORY
- Last AWE:
- PCP: 
- Last Labs:

GOALS
- Weight Goal:
- Non-scale Goals:

____ is a ____ here for weight loss consultation visit #2. 

PMHx, PSHx, FMHx, SocHx below

LAB REVIEW:
- Obtained: 
- Hba1C:
- TSH:
- Other: 

EATING DISORDER SCREENING
Start with SCOFF https://qxmd.com/calculate/calculator_859/sick-control-one-fat-food-scoff
If SCOFF is positive, complete EDDS https://qxmd.com/calculate/calculator_562/eating-disorder-diagnostic-scale-edds

SLEEP DISORDER SCREENING (if applicable)
https://qxmd.com/calculate/calculator_85/epworth-sleepiness-scale
https://qxmd.com/calculate/calculator_531/stop-bang-score-for-obstructive-sleep-apnea

EMOTIONAL HEALTH:
PHQ9 = 
GAD7 = 

BARIATRIC SURGERY CANDIDACY
BMI > 35 with one or more adverse health consequences: No
BMI > 40 with or without adverse health consequences: No

LMP:

Plan

We had a visit today to review your weight journey. 

I have scheduled a second video visit to review your medical history in more detail.

I have also ordered labs that I have digitally sent to Labcorp. You will see this order form populate in the chat as well. I have sent the following labs:
- CBC
- CMP
- HbA1C
- TSH

To best optimize our next visit, please have the following items ready:
- obtain blood pressure and heart rate (most pharmacies have a machine)
- complete the two mental health questionnaires: PHQ9 and GAD7, that I will send you after this visit. You will see these show up in the chat. 
- the fasting labwork one week before our next appointment so that results are back in time for review. 

Please do not hesitate to reach out with any additional questions or concerns! 

Best,
William Kelly

We have reviewed your medical history and weight journey and what has worked and not worked. 

Your starting BMI: 
Your starting weight: 

Medications to support weight loss is best combined with behavioral therapy, exercise, and a healthy diet. 

MEDICATION: 
 We decided on Semaglutide (brand names: Ozempic / Wegovy). I have sent the following prescription to your pharmacy:
- Wegovy 0.25mg, Inject 0.25mg SQ weekly, #1 pen, 0 refills
- Ozempic 0.25mg, Inject 0.25mg SQ weekly, #1 pen, 0 refills
- Zepbound 2.5mg, Inject 2.5mg SQ weekly, #4 pens, 0 refills
- Mounjaro 2.5mg, Inject 2.5mg SQ weekly, #4 pens, 0 refills
- Saxenda 18mg/3ml, Inject 0.6mg once daily for 1 week, then may increase by 0.6mg weekly as tolerated to max of 3mg/day, #2 pens, 0 refills

Your insurance may require a Prior Auth. If we do not have enough information to complete the Prior Auth or it is denied, you can consider using the savings cards: 
- https://www.ozempic.com/savings-and-resources/save-on-ozempic.html
- https://www.wegovy.com/coverage-and-savings/wegovy-savings-and-support.html 
- https://mounjaro.lilly.com/savings-resources?redirect-referrer=https%3A%2F%2Fwww.google.com%2F
- https://www.zepbound.lilly.com/coverage-savings

INSTRUCTION ON INJECTIONS:
Ozempic: https://www.youtube.com/watch?v=CwVFtt8SKT4
Wegovy: https://www.youtube.com/watch?v=2Cl5C7vMBgI
Mounjaro: https://www.youtube.com/watch?v=xZlE1e6illA
Zepbound: https://www.youtube.com/watch?v=eG7MvEE9Zek Saxenda: https://www.youtube.com/watch?v=3dpjpQaX9x0


NUTRITIONAL PRESCRIPTION:
- Eat 2 to 3 set healthy balanced meals per day. 
- Eliminate ultra-processed foods of minimal nutritional value, such as “sweets” and “junk food,” and ultra-processed meats, such as bacon, sausage, hot dogs, and pastrami. 
- Focus on healthful proteins and fats, vegetables, leafy greens, fruits, berries, nuts, legumes, and whole grains. 
- Avoid eating after 6-7 PM when the body is less likely to burn excessive calories and more likely to convert them to fat.

EXERCISE PRESCRIPTION:
- 5000 to 10,000 steps per day
- 150 to 300 minutes or more moderate-intensity aerobic activity per week or 75 – 150 minutes or more vigorous intensity aerobic activity per week
- Resistance training/muscle strengthening at least two times a week

I recommend ensuring adequate restorative sleep of 7-8 hours per night and adequate hydration throughout the day. 

We also reviewed your risks for sleep apnea, and at this time, you are NOT at risk for sleep apnea.

A follow-up is recommended in 1 month. When patients first start their weight loss journey, it is common for the initial weight loss to be not reflected on the scale. However, you should start feeling more energetic and notice your clothes fit better by the end of the month.  

Please do not hesitate to reach out with any additional questions or concerns! 

Best,
William Kelly

Education

GAHT (MASC)

HPI

____ is a __ year old transgender man who presents for a follow-up on Gender Affirming Care. 

-- Current medication: Testosterone __ ml SQ weekly
-- Duration on this dose: __ months
-- How long on this medication: since ___
--Ease of use: No issues

How does the medication improve your life? 
√ 
√ 
√ 

Are there things about it that you do not like?
• 
• 

-SPECIFIC SIDE EFFECTS-
Local reaction to injection site? 
Low energy? 
Breast tenderness? 
Low Libido? 
Mood change? 
Decreased muscle mass? 
Anxiety/Depression change? 

Surgical Goals: 

-BLOOD PRESSURE-
Last reading: 

-CAD RISK FACTORS-
  - FMHx: 
  - h/o HTN or DM: 
  - h/o HLD: 
  - Smoking: 
  - Overweight: 

-- Target symptoms not being addressed: All being addressed as above
-- Current therapist: Denies

____ is a __ year-old ____ who presents to Circle Medical to establish care for their Gender Affirming Hormone Therapy treatment. 

Name: 
Pronouns: 
Gender Identity: 
Sex Recorded at Birth: 

Preferred names for body parts: 
Any Gender Affirming Surgeries:
Sexual Orientation: 
Relationship Status:
Sexual practices:
*What kind of sex practices do you engage in? Is there any sort of penetration, if so with where, and with what?*
   - Birth Control: If applicable
   - Last STI testing: 

When did you first realize your gender identity did not align with the sex assigned at birth? 
How as your transition been?
How has this affected:
 - Home:
 - Work:
 - Relationships:

 The patient does exhibit a marked incongruence between their experienced/expressed gender and their assigned gender at birth, which has been ongoing for more than 6 months. This is manifested by:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
- A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender
- A strong desire to be treated as the other gender
- A strong conviction that one has the typical feelings and reactions of the other gender 

Ultimate goals for hormonal transition:
Ultimate goals for surgical transition:

Any fertility desire or prior egg preservation?
Last PAP:
Mammogram: 

MASCULINIZING HORMONE EFFECTS: reviewed with patient
Reversible Side effects: Redistribution of fat, muscle growth, cessation of menses, vaginal dryness/atrophy, acne/oily skin, pelvic pain, weight gain, emotional changes, increased sweating, Tendon injury
Irreversible Side effects: Clitoral enlargement, scalp hair loss, deepened voice, possible sterilization/infertility
Testosterone won’t: cause muscle growth super fast, always stop menses, prevent pregnancy

PMHx: 
OSA: *Do you snore or wake up gasping for air*?
CAD: Do you have any history of heart problems, palpitations, arrhythmias?
   - FMHx of CAD or stroke:
HTN history:
   - Last BP:
   - FMHx:
Smoking:
Personal or family history of BRCA or endometrial CA:

MENTAL HEALTH SCREENING:
Anxiety: GAD7 reviewed, 
Depression: PHQ9 reviewed,
Mental Health Provider: 
   - Practice Name:
Other Providers (OBGYN, surgeon, PCP):
Therapist:

___ is a __ year-old Transman who presents for Gender Affirming Hormone Therapy visit #2. 

-LABS-
  • Performed?: 
  • T level: 
  • E level: 
  • Hgb/hct: 
  • LDL: 
  • HDL: 

SCREENINGS:
  • Pap smear: 
  • Mammogram: NA

Medical records? NA

Agreed to consent? 

Confirm ultimate goals for hormonal transition:

Current therapist/Counselor? 
Appointment date? 

Chosen medication? Testosterone cypionate
Route? SQ, IM, or Transdermal
Normal or microdosing: Normal

MASCULINIZING HORMONE EFFECTS: Reviewed with patient
Reversible Side effects: Redistribution of fat, muscle growth, cessation of menses, vaginal dryness/atrophy, acne/oily skin, pelvic pain, weight gain, emotional changes, increased sweating, Tendon injury
Irreversible Side effects: Clitoral enlargement, scalp hair loss, deepened voice, possible sterilization/infertility
Testosterone won’t: cause muscle growth super fast, always stop menses, prevent pregnancy

___ is a ___ year-old male who presents to Circle Medical to establish care for their Gender Affirming Hormone Therapy treatment. 

Name: 
Pronouns: 
Gender Identity: 
Sex Recorded at Birth: 

When did they start HRT:
Previous Provider Name:
   - Clinic: 
Current Hormone regimen:
   - Last dose: 
   - Last Labs:
Previous Meds/routes: IM, SQ, gel, patches?

Changes since last visit: 
√ 

Desired changes experienced:
√ 
√ 

Changes still desired / not yet seen:
✘ 

Undesired side effects / dislikes: 
✘ 
✘

-Specific masculizing effects-
Masculinizing effects:
Deepening of voice: 
Skin oiliness/acne: 
Facial/body hair growth: 
Increased muscle mass/strength:
Fat redistribution: 
Cessation of menses: 
    - LMP:
Clitoral enlargement:
Vaginal dryness/atrophy: 

Preferred names for body parts: Anatomical
Sex Organs at birth: Traditional female organs at birth
Any Gender Affirming Surgeries: 
Sexual Orientation: 
Relationship Status:
Sexual practices:
   - Birth Control: If applicable
   - Last STI testing: 

Any fertility desire or prior egg preservation?
Last PAP:
Mammogram:

PMHx: 
OSA: Denies snoring
CAD: denies h/o CAD, Palpitations, CP, or arrhythmias
   - FMHx of CAD or stroke: Denies
HTN history:
   - Last BP:
   - FMHx:
Smoking:
Personal or family history of BRCA or endometrial CA:

MENTAL HEALTH SCREENING:
Anxiety: GAD7 reviewed, 
Depression: PHQ9 reviewed,
Mental Health Provider: 
   - Practice Name:
Other Providers (OBGYN, surgeon, PCP):
Therapist:

Plan

 It was a pleasure seeing you today. You were seen today for the continuation of your gender-affirming care. You have consented to gender-affirming hormone therapy.

Your dose of Testosterone was ______ today. I sent a 3-month supply to your pharmacy:
- Testosterone Cypionate 200mg/ml, Inject __ ml SQ weekly, #2, 0 refills
- BD 1ml Syringe, #12, 0 refills
- BD 18G needle, #12, 0 refills (for drawing up)
- BD 25G needle, #12, 0 refills (for injecting into the fat)
- BD 21G needle, #12, 0 refills (for injecting into the muscle) -- if applicable

We discussed at length during the appointment all precautions, contraindications, and side effects to treatment. We discussed if there are any side effects to stop the medication and follow up immediately or go to an ER for evaluation.

We booked an appointment in 3 months for a follow-up. I will order blood work today, but I want you to get this done 1-2 weeks before our next appointment, mid-way between injections. 
-OR-
I sent you an appointment reminder that will pop up in 2 months to book with me 1 month later. I will order blood work today, but I want you to get this done 1-2 weeks before our next appointment, mid-way between injections. 

Thank you for choosing Circle Medical for your care. Please do not hesitate to reach out with any additional questions or concerns! 
- William Kelly, FNP-C

You were seen today for initiation of gender-affirming care. We discussed that your symptoms are consistent with gender dysphoria and would benefit from gender-affirming therapy.

We ordered lab work for you to get drawn at a local Labcorp. The order form has been sent to the chat, and the
staff at LabCorp may want to see this when you present to get drawn. You will need to fast at least 8 hours before
getting it drawn, and provide a urine sample while there. Most Lab-Corps accept walk-ins.
You can find a local Lab Corp here: https://www.labcorp.com/precheck

We ordered the following labs:
- CBC to check for anemia
- CMP to check your electrolytes, kidneys, glucose, and liver
- Lipids to check for cholesterol
- STI testing including HIV and syphilis, Gonorrhea and chlamydia
- Hormone levels (estrogen and testosterone)

We also require an annual physical to be performed within the last 12 months, and your last one was _________. We will request medical records to try and get these before your next appointment. 

I have booked you an appointment in 2 weeks to review your blood work and start you on hormone therapy as long as there are no major abnormalities. Please check your blood pressure by then and write down your numbers. If you don’t have a cuff at home.
You can buy one on amazon here: https://tinyurl.com/bdeyrba5

We have also sent you a request for consent in the “chat” section of the App. Please take your time to review and respond back “I agree” in the chat if you consent to gender affirming hormone replacement therapy. You have stated you have full capacity to give informed consent and understand all risks, benefits, alternatives, unknowns, and limitations.

Please send any previous records that you may have to us at records@circlemedical.com.

At Circle, our values are to provide a superior patient experience with your optimal wellness in mind. Please reach out if you have any further questions! Thank you for choosing Circle Medical for your care, and it was a pleasure getting to know you today!
- William Kelly, FNP-C

You were seen today for initiation of gender affirming care. Your blood work was reviewed today, which we will be repeating every 3 months for the first year of hormone therapy. We discussed that your symptoms are consistent with the DSM 5 criteria for gender dysphoria and would benefit from gender affirming therapy. 

Gender Dysphoria was used as an ICD 10 billing code to support insurance coverage for services today. We strongly believe that being transgender is not a mental illness and using such a code stigmatizes gender non-conformity and creates barriers to medical care.
CM strives to support the resilience and positive development of the LGBTIA+ community. We treat all of our patients with dignity, respect, and affirmation that they deserve.

You have consented to gender affirming hormone therapy. To learn more in-depth about the changes you can expect to your body after taking Testosterone, please read this: https://transcare.ucsf.edu/article/information-testosterone-hormone-therapy

We have started you on Testosterone today:
- Testosterone Cypionate 200mg/mL, Inject 0.3mL into subcutaneous fat of abdomen or thigh weekly, #2mL, 0 refills
- BD 1ml Syringe, #12, 0 refills
- BD 18G needle, #12, 0 refills (for drawing up)
- BD 25G needle, #12, 0 refills (for injecting into the fat)

Here are some good links to help you learn how to inject:
Educational PDF: https://fenwayhealth.org/wp-content/uploads/2015/07/COM-1880-trans-health_injection-guide_small_v2.pdf
Drawing up: https://www.youtube.com/watch?v=ApWiQH4rzlAOh 
Subcutaneous Injection: https://www.youtube.com/watch?v=DJd02xCNNc0

Here is another link to an instructional video about injectable medications and how to dose: 
https://www.plannedparenthood.org/planned-parenthood-greater-texas/self-injection-videos 

We discussed at length during the appointment all precautions, contraindications, and side effects to treatment. You agreed you have capacity in decision making. We discussed the risks and benefits of hormones and that some side effects may be non reversible and you verbalized understanding. We discussed if there are any side effects to stop the medication and follow up immediately or go to an ER for evaluation.

We discussed the importance of following up with a therapist throughout your gender affirming care.

We have scheduled a followup appointment in 4 weeks where we'll see how you're feeling, how the injections are going, and renew your prescription. After that we will see you at the 3 month mark to repeat lab work and adjust your dose.

 We recommend checking a blood pressure every so often, especially while on testosterone. This can sometimes be done at a local pharmacy or grocery store that has a machine, and there are also affordable blood pressure cuffs you can buy for your home. Try to check it at least once before your next visit and write down your numbers. 
If you don’t have a cuff at home, you can buy one on amazon here: https://tinyurl.com/mrb5famr 

Thank you for choosing Circle Medical for your care. Please don't hesitate to reach out if you have any questions!

You were seen today for gender affirming care. We discussed that we will be continuing your gender affirming hormone therapy.

We ordered lab work for you to get drawn at a local Labcorp. The order form has been sent to the chat, and the staff at LabCorp may want to see this when you present to get drawn. You will need to fast at least 8 hours before getting it drawn. Most Lab-Corps accept walk-ins.
You can find a local Lab Corp here: https://www.labcorp.com/precheck

We ordered the following labs: 
- CBC to check for anemia
- CMP to check your electrolytes, kidneys, glucose, and liver
- Lipids to check for cholesterol
- HbA1C to screen to diabetes
- Hormone levels (testosterone and estrogen)

We have sent you a bridge prescription for 1 month of your Testosterone, and will see you in 4 weeks to go over your blood work and continue your hormone care. We have sent the following prescription into the pharmacy:
- Testosterone Cypionate 200mg/1mL, Inject 0.35mL intramsucularly every week, #2mL, 0 refills

I have booked you an appointment with you next month to review your blood work and continue your hormone therapy. Please check your blood pressure by then and write down your numbers. If you don’t have a cuff at home, you can buy one on amazon here: https://tinyurl.com/bdeyrba5

We have also sent you a request for consent in the “chat” section of the App. Please take your time to review and respond back “I agree” in the chat if you consent to gender affirming hormone replacement therapy. You have stated you have full capacity to give informed consent and understand all risks, benefits, alternatives, unknowns, and limitations.

Please send any previous records that you may have to us at records@circlemedical.com.
We have also sent a medical records request from your previous Provider. You should be getting an email with 24-48 hours with a release form to be signed, and we will let you know in the chat when we sent that. 

Below is a list of gender affirming counseling/therapy services. We strongly recommend therapy during the entire gender affirming process for continued support:
https://www.pridecounseling.com – queer/trans specific
https://www.betterhelp.com – not queer/trans specific but sensitive
https://www.marigoldhealth.com – not queer/trans specific but sensitive

At Circle, our values are to provide a superior patient experience with your optimal wellness in mind. Please reach out if you have any further questions! Thank you for choosing Circle Medical for your care!

Plan Add-Ons

- Testosterone Cypionate 200mg/mL, Inject 0.3mL intramusucular into thigh or buttock weekly, #2mL, 0 refills
- 6 of each of the following: 1mL syringes, 18g needles (for drawing up), and 22g needles (for injecting) 

Here are some good links to help you learn how to inject:
Educational PDF: https://fenwayhealth.org/wp-content/uploads/2015/07/COM-1880-trans-health_injection-guide_small_v2.pdf
Drawing up: https://www.youtube.com/watch?v=ApWiQH4rzlA
Intramuscular Injection: https://www.youtube.com/watch?v=FgCCO9Gqt1Q
Another Video: https://www.plannedparenthood.org/planned-parenthood-greater-texas/self-injection-videos

We have started you on Testosterone today:
- Androgel 1.62% 20.5mg/pump,Apply 2 pumps on shoulders and upper arms daily, #1 bottle, 0 refills

Here is a good video of someone using the Androgel: https://www.youtube.com/watch?v=Wofod0CydGQ 

Apply this to clean dry skin every morning, best after a shower. Apply to upper arms and shoulders (the area covered by a short T-shirt). Let this dry before putting on your shirt. Avoid swimming, showering, or washing the application site for at least 2 hours after application. If you plan on having skin-to-skin contact with any person or animal, please wash with warm water and soap beforehand.

- BD 1ml Syringe, #12, 0 refills
- BD 18G needle, #12, 0 refills (for drawing up)
- BD 25G needle, #12, 0 refills (for injecting into the fat)

Education

FINASTERIDE EDUCATION:
Finasteride is a medication initially developed for treating male pattern baldness and, in higher doses, an enlarged prostate. It functions by reducing the production of dihydrotestosterone (DHT), a hormone contributing to hair loss in individuals undergoing masculinizing hormone therapy, including trans men.

• How to Take: Finasteride is typically administered orally, usually as a 1mg tablet once a day for hair loss. Consistency in taking it at the same time every day is crucial for effectiveness.
• Onset of Effects: Improvement may be noticeable after about three months, with full effects more apparent after six months to a year of continuous use.
• If Discontinued: Stopping finasteride typically leads to the gradual loss of its benefits over six to twelve months.

Potential Side Effects
• Sexual Side Effects: In trans men, the most noticeable side effect may be a change in libido. Other effects seen in cisgender men, such as erectile dysfunction or reduced ejaculate volume, may not be relevant depending on your transition status and surgical history.
• Effects on Hormone Replacement Therapy (HRT): Finasteride can potentially slow or reduce the growth of facial and body hair due to its impact on DHT levels. This is an important consideration for trans men who are seeking to increase these secondary sex characteristics.
• Psychological Effects: Though rare, some individuals may experience mood changes like depression or anxiety.
• Other Side Effects: There might be minor reactions such as skin rash, breast tenderness, or pain in the groin area.

GAHT (FEM)

HPI

___ is a __ year-old ___ who presents for follow-up on Gender Affirming Care. They were started on Estrogen 1 month ago.

-- Current medication: estrogen 2mg daily
-- Duration on this dose: 1mo
-- How long on this medication: since 8/17/22
--Ease of use: 

How does the medication improve your life? 

Are there things about it that you do not like? 

Considered surgical options?

–CAD risk factors? No
–Smoking? Vapes, former smoker

–Social impact?

-- Specific side effects?
Local reaction to injection site?
Low energy?
Breast tenderness?
Libido?
Mood change?
Decreased muscle mass?
Anxiety/Depression change?

-- Target symptoms not being addressed: As abovee
-- Current therapist:

___ is a __ year-old male who presents to Circle Medical to establish care for their Gender Affirming Hormone Therapy treatment. 

Name: 
Pronouns: 
Gender Identity: 
Sex Recorded at Birth: 

Preferred names for body parts: 
Any Gender Affirming Surgeries:
Sexual Orientation: 
Relationship Status:
Sexual practices:
*What kind of sex practices do you engage in? Receptive anal intercourse? Penetrative intercourse?
   - Condoms:
   - Last STI testing: 

When did you first realize your gender identity did not align with the sex assigned at birth? (at least 6 months for diagnosis): 
How has your social transition been? 
How has it affected:
 - Work:
 - Home:
 - Relationships:

 The patient does exhibit a marked incongruence between their experienced/expressed gender and their assigned gender at birth, which has been ongoing for more than 6 months. This is manifested by:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
- A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender
- A strong desire to be treated as the other gender
- A strong conviction that one has the typical feelings and reactions of the other gender 

What are your ultimate goals for hormonal transition?
What are your ultimate goals for surgical transition (Refer for surgery)? 

Fertility desire/Any interest in sperm preservation? 
Smoking? 
Last Labs:

MENTAL HEALTH SCREENING:
Anxiety: GAD7 reviewed, 
Depression: PHQ9 reviewed,
Medications:
Mental Health Provider: 
   - Practice Name:
Other Providers (OBGYN, surgeon, PCP):
Therapist (talked to therapist or counselor in past about transition / HRT?

PDMP: Reviewed, consistent, last Rx 

FEMINIZING EFFECTS OF HRT (discussed with patient)
Redistribution of body fat
Decrease in muscle mass and strength
Softening of skin/decreased oiliness
Decreased sexual desire
Decreased spontaneous erections
Breast growth
Smaller/softer testes
Decreased terminal hair growth
Voice change

____ is a __ year old ____ who presents for Gender Affirming Care visit #2. 

Was blood work performed? 
Results? 
Up to date on screenings?
Medical records? 

Agreed to consent? Consent in chat

Confirm ultimate goals for hormonal transition: 
Surgical goals: 

Current therapist/Counselor? 
Appointment date? 

Chosen medication? Estrace 2mg
Route? PO

Discussed desired effects: softer less oily skin, increased fat around hips and breast, decreased muscle mass, thinner/slower growing facial/body hair, decreased spontaneous erections, 
Discuss side effects: worsened migraines, mood swings, hot flashes, weight gain, decreased libido, erectile dysfunction
Discuss non reversible side effects: Breast development, decreased testicular volume, possible infertility

Plan

 It was a pleasure seeing you today. You were seen today for the continuation of your gender-affirming care. You have consented to gender-affirming hormone therapy.

Your dose of Estrogen was ______ today. I sent a 3-month supply to your pharmacy:
- Estrace 2mg, Take 1 tab PO in AM daily, #90, 0 refills

We discussed at length during the appointment all precautions, contraindications, and side effects to treatment. We discussed if there are any side effects to stop the medication and follow up immediately or go to an ER for evaluation.

We booked an appointment in 3 months for a follow-up. I will order blood work today, but I want you to get this done 1-2 weeks before our next appointment. 
-OR-
I sent you an appointment reminder that will pop up in 2 months to book with me 1 month later. I will order blood work today, but I want you to get this done 1-2 weeks before our next appointment. 

Thank you for choosing Circle Medical for your care. Please do not hesitate to reach out with any additional questions or concerns! 
- William Kelly, FNP-C

You were seen today for initiation of gender affirming care. We discussed that your symptoms are consistent with gender dysphoria and would benefit from gender affirming therapy. 

We ordered lab work for you to get drawn at a local Labcorp. The order form has been sent to the chat, and the staff at LabCorp may want to see this when you present to get drawn. You will need to fast at least 8 hours before getting it drawn, and provide a urine sample while there. Most Lab-Corps accept walk-ins.
You can find a local Lab Corp here: https://www.labcorp.com/precheck

We ordered the following labs: 
- CBC to check for anemia
- CMP to check your electrolytes, kidneys, glucose, and liver
- Lipids to check for cholesterol
- HbA1C to screen to diabetes
- STI testing including HIV, Syphilis, Gonorrhea, and Chlamydia 

I have booked you an appointment in 2 weeks to review your blood work and start you on hormone therapy as long as there are no major abnormalities. Please check your blood pressure by then and write down your numbers. If you don’t have a cuff at home, you can buy one on amazon here: https://tinyurl.com/bdeyrba5

We have also sent you a request for consent in the “chat” section of the App. Please take your time to review and respond back “I agree” in the chat if you consent to gender affirming hormone replacement therapy. You have stated you have full capacity to give informed consent and understand all risks, benefits, alternatives, unknowns, and limitations.

Please send any previous records that you may have to us at records@circlemedical.com.

At Circle, our values are to provide a superior patient experience with your optimal wellness in mind. Please reach out if you have any further questions! Thank you for choosing Circle Medical for your care, and it was a pleasure getting to know you today!
- William Kelly, FNP-C

You were seen today for initiation of gender affirming care and have consented to gender affirming hormone therapy.

We discussed that your symptoms are consistent with the DSM 5 criteria for gender dysphoria and would benefit from gender affirming therapy. 

Gender Dysphoria was used as an ICD 10 billing code to support insurance coverage for services today. We strongly believe that being transgender is not a mental illness and using such a code stigmatizes gender non-conformity and creates barriers to medical care.
CM strives to support the resilience and positive development of the LGBTIA+ community. We treat all of our patients with dignity, respect, and affirmation that they deserve.

Your blood work was reviewed today. We will repeat your blood work in 3 months.

We have started you on the following:
- Estrace 2mg, Take 1 tablet daily, #30, 0 refills
GoodRx Coupon: https://tinyurl.com/43eybecu

We discussed at length during the appointment all precautions, contraindications, and side effects to treatment. You agreed you have capacity in decision making. We discussed the risks and benefits of hormones and that some side effects may be non reversible and you verbalized understanding. We discussed if there are any side effects to stop the medication and follow up immediately or go to an ER for evaluation.

If you develop any confusion, weakness or numbness on one side of your body, or trouble speaking, please seek care at a local emergency room. If you develop redness, swelling, or pain of your leg/calf, or severe chest pain or shortness of breath, this could mean there is a blood clot. Seek care for this as well at a local ER. 

We discussed the importance of following up with a therapist throughout your gender affirming care.

We discussed adding on a T blocker as well as potentially progesterone later on down the road.

We have scheduled an appointment in 4 weeks to evaluate how you are doing and renew your prescription. 

Thank you for choosing Circle Medical for your care. Please don't hesitate to reach out if you have any questions!
 - William J. Kelly, FNP

Education

MISC VISITS

Birth Control

- BIRTH CONTROL - 
  
  LMP:
Previous BC: 
  - Any SE/Issues:

Age ≥35 years?: No
Smoker?:
H/o HTN?:
H/o Migraine w/ aura?:
PMHx or FMHx of Breast/GYN CA?:

Options:
 - IUD:
 - Nuva Ring
 - DEPO:
 - OCP:
 - mini pill:

Desire for period: 
Regimen: 24/4 preferred (less time off hormone, less withdrawal)

Effectiveness: 0.3% with perfect use, typical use 7%
Backup: Use x 1 week unless actively on period
Condoms: Still use to protect against STIs
Effects: Spotting within first few months normal, periods may become lighter, nausea or breast tenderness for few months, may improve menstrual cramps

OCP go-to: Microgestin Fe 24 (low estrogen), Ortho novum 1/35 (higher estrogen)

We discussed starting birth control for ______ .

We are going to start you on an oral combination contraceptive pill, which has both estrogen and progesterone in it. This should help give you stable hormone levels for 24 days, then 4 days of "placebo" pill where you will have your period. 

We talked about risks of blood clots, and if you develop redness/pain/swelling in one leg, chest pain, or SOB, please go to the ER. 

Possible side effects:
Some common side effects of birth control pills after first starting include breast tenderness, nausea, bloating, unscheduled bleeding or spotting, or a change in sex drive. These typically resolve within 2-3 months of starting the pill.

STARTING
There are three ways to start your first cycle of oral contraceptives:

1. First Day Start - Take your first pill during the first 24 hours of your menstrual cycle. No back-up contraceptive method is needed when the pill is started the first day of your menses.

2. Sunday Start - Wait until the first Sunday after your menstrual cycle begins to take your first pill. With this option use another method of birth control for the first 7 days of the first cycle only.

3. Today Start - Start the pill today. If you have had unprotected sexual intercourse since your last period, perform a pregnancy test prior to starting the pill. If it is negative, start the pill today. Use another method of birth control such as condoms or spermicide the first seven days of the first cycle of use.

IMPORTANT REMINDERS
1. You will need to use a back-up contraceptive method such as condoms for the first 7 days after starting your pills.
2. You will need to take a pill at the same time every day. Skipping pills can increase the chance of getting pregnant. Birth control pill packets usually include 4 to 7 days of hormone-free pills each month. It is during these hormone free days that women get their period.
3. Birth control pills do not protect women from sexually transmitted infections (STI). I recommend condom use for all sexual encounters and STI screening prior to encounters with new partners.
4. Women over the age of 35 and smoke cigarettes are at increased risk for adverse events such as heart attack and stroke when taking birth control pills. I recommend abstaining from smoking cigarettes. If you do decide to start smoking, please follow-up so we can discuss a safer birth control method for you.
5. Certain medicines can decrease the effectiveness of birth control pills. These include: medicines to prevent seizures (anticonvulsants), antibiotics to treat tuberculosis (rifampin) and herbal medicines such as St. John’s Wort. If you need to take these medications, you will need to use a back-up contraceptive method.

MISSED PILLS:
1. Single missed pill: take it as soon as you remember and continue taking one pill each day. You can take 2 pills in one day if needed.
2. If you missed 2 or more pills and had unprotected intercourse during the week, you can take emergency contraception, also known as the “morning after pill” to reduce your risk of pregnancy. You can purchase this over-the-counter at a pharmacy. If you need to take the morning after pill, do it as soon as possible after sex.

Oral contraceptives, commonly known as birth control pills, are medications taken to prevent pregnancy. Besides birth control, they can also be used to regulate menstrual cycles, reduce menstrual cramps, and manage certain hormonal conditions. It’s important to understand how these pills work, their benefits, potential side effects, and risks.

Oral contraceptives contain synthetic forms of hormones (estrogen and/or progestin) that prevent ovulation (the release of an egg from the ovaries). They also thicken cervical mucus to prevent sperm from reaching an egg and thin the lining of the uterus to prevent a fertilized egg from attaching.

When starting oral contraceptives, you may experience some side effects as your body adjusts to the hormones. These often resolve within a few months. Common side effects include:

• Nausea
• Breast tenderness
• Weight gain
• Lighter periods or spotting between periods
• Mood changes
If these side effects persist or become bothersome, consult your healthcare provider.

While oral contraceptives are safe for most women, they can have serious side effects in rare cases. It’s crucial to be aware of these risks:
• Blood clots: Oral contraceptives can increase the risk of developing blood clots, especially in smokers or women over 35.
• Stroke or heart attack: This risk is higher in women who smoke, especially those over 35, and those with certain health conditions like hypertension.
• High blood pressure: Regular blood pressure checks are recommended.
• Liver problems: Rarely, oral contraceptives can affect liver function.

Signs of serious problems include:
• Severe leg pain or swelling (possible blood clot)
• Sudden shortness of breath (possible blood clot in the lung)
• Sudden, severe headache or vomiting, dizziness or fainting, disturbances in vision or speech, weakness, or numbness in an arm or leg (possible stroke)
• Chest pain or heaviness (possible heart attack)

Who Should Not Take Oral Contraceptives:
• A history of blood clots, stroke, or heart disease.
• Severe migraines, especially with aura.
• Liver disease.
• Breast or endometrial cancer.
• Uncontrolled high blood pressure.

Remember:
• Oral contraceptives do not protect against sexually transmitted infections (STIs). Use condoms for STI protection.
• Adherence is key. Take your pill at the same time every day.
• If you miss a pill, follow the instructions on your pill packet or contact your healthcare provider.

PrEP

-PrEP-
We also discussed for HIV Pre-Exposure prophylaxis (PrEP). 

PrEP is a concept that involves taking an anti-retroviral medication daily AND practicing risk reduction strategies, including condom use and knowing your partner's status. The medication itself will not protect you from other sexually transmitted diseases such as herpes, genital warts, gonorrhea or chlamydia.  

I have ordered labs to check to make sure it is okay to restart PrEP, including: 
- CBC
-Comprehensive metabolic panel (includes kidney function test)
-HIV
-Syphilis
-Gonorrhea/Chlamydia - urine
-Hepatitis screen
-Hepatitis immunity check

Once i get the results, I will send in a 90-day supply of PrEP as we discussed:
- Truvada, Take 1 tab PO daily, #90, 0 refills

Reminders
- During the first 7 days of taking the medication, you are NOT protected against HIV and should take additional precautions. (21 days if you engage in receptive vaginal sex)
- Short-term side effects (up to a month) may include loose stools, nausea, and headaches. Most patients do not experience side effects after that initial period. 
- A follow-up visit and blood work every 3 months are needed for the renewal of the medication. **Please schedule a follow-up visit with me in 3 months (this can be done via VIDEO).** 
- Should you develop any symptoms of swollen lymph nodes, fever, extreme fatigue, and/or a new rash, please contact us immediately so you can be tested for HIV.

You are going to send me your vaccine records so we know if you are due for anymore vaccines. You can also learn more about PrEP on the CDC's website (https://www.cdc.gov/hiv/basics/prep.html)

-THE 2-1-1 METHOD-
The 2-1-1 method, also known as on-demand PrEP (pre-exposure prophylaxis), is a way to take Truvada for HIV prevention. This method is especially useful for individuals who are at risk of HIV exposure but do not have sex frequently enough to warrant daily PrEP. 
• Before Exposure: Take 2 Pills 2 to 24 hours before you anticipate having sex, take two pills of Truvada at once. This pre-loads your body with the medication.
• Day of Exposure: Take 1 Pill 24 hours after your first dose
• After Exposure: Take 1 every 24 hours after your possible exposure during sexual activity

Additional Points:
• Continued Activity: If you continue to have sex or anticipate more sex, continue taking one pill every 24 hours until you have had two sex-free days. After two sex-free days, you do not need to take any more pills.
• Missed Doses: If you miss a dose, take it as soon as you remember, but do not double the dose if it's close to the time for your next dose.
• Regular Testing: Regular HIV testing and consultations with your healthcare provider are crucial while using PrEP.
• Other Safety Measures: Remember that while PrEP reduces the risk of HIV, it does not protect against other sexually transmitted infections (STIs). Using condoms is still recommended for broader STI prevention.

Side Effects:
• Nausea: Some people experience nausea when they first start taking PrEP, but it often goes away with time.
• Headache: Headaches are a common side effect but usually decrease in frequency and intensity over time.
• Diarrhea: This can occur, especially when starting the medication.
• Abdominal Pain: Some individuals report mild to moderate abdominal discomfort.
• Weight Loss: A small amount of weight loss is sometimes reported.
• Fatigue: Feelings of tiredness or general weakness may occur.

More serious side effects (much less common):
• Kidney Problems: PrEP can affect kidney function, which is why kidney function tests are recommended before starting and during treatment.
• Bone Density Reduction: There may be a decrease in bone mineral density, although this is typically minor and reversible after stopping the medication.
• Liver Health: Some people may experience changes in liver health, particularly those with hepatitis B or C.
• Lactic Acidosis: A rare but serious condition involving the buildup of lactic acid in the blood.
• Immune Reconstitution Syndrome: In individuals with undiagnosed HIV who start PrEP, there is a risk of immune reconstitution syndrome, a potentially serious reaction to the treatment of HIV.
• Worsening of Hepatitis B: In individuals with Hepatitis B, stopping PrEP could worsen hepatitis symptoms.

You can also learn more about PrEP on the CDC's website (https://www.cdc.gov/hiv/basics/prep.html)

-DAILY METHOD INSTRUCTIONS-
The daily method for taking Truvada for PrEP (pre-exposure prophylaxis) is a recommended way for HIV prevention, especially for those with frequent exposure risk. This approach involves taking Truvada every day to maintain a constant level of protection against HIV.

Daily Dosage: Take one pill of Truvada once every day at the same time. Consistent daily intake is crucial for maintaining the medication's effectiveness.

Additional Points:
• Starting PrEP: It's important to start taking PrEP as per your healthcare provider's instructions and after confirming you are HIV-negative.
• Continuity: Even if you don't have sex every day, continue taking the pill daily to maintain its effectiveness.
• Missed Doses: If you miss a dose, take it as soon as you remember. However, if it's almost time for your next dose, skip the missed dose and continue with your regular schedule. Do not take two doses at once.
• Regular Testing: Regular HIV testing (every 3 months) is important while using daily PrEP. Additionally, routine kidney function tests should be performed.
• Other Safety Measures: PrEP reduces the risk of HIV but does not protect against other sexually transmitted infections (STIs). Therefore, using condoms and other safety measures is still recommended for broader STI prevention.

Side Effects:
• Nausea: Some people experience nausea when they first start taking PrEP, but it often goes away with time.
• Headache: Headaches are a common side effect but usually decrease in frequency and intensity over time.
• Diarrhea: This can occur, especially when starting the medication.
• Abdominal Pain: Some individuals report mild to moderate abdominal discomfort.
• Weight Loss: A small amount of weight loss is sometimes reported.
• Fatigue: Feelings of tiredness or general weakness may occur.

More serious side effects (much less common):
• Kidney Problems: PrEP can affect kidney function, which is why kidney function tests are recommended before starting and during treatment.
• Bone Density Reduction: There may be a decrease in bone mineral density, although this is typically minor and reversible after stopping the medication.
• Liver Health: Some people may experience changes in liver health, particularly those with hepatitis B or C.
• Lactic Acidosis: A rare but serious condition involving the buildup of lactic acid in the blood.
• Immune Reconstitution Syndrome: In individuals with undiagnosed HIV who start PrEP, there is a risk of immune reconstitution syndrome, a potentially serious reaction to the treatment of HIV.
• Worsening of Hepatitis B: In individuals with Hepatitis B, stopping PrEP could worsen hepatitis symptoms.

You can also learn more about PrEP on the CDC's website (https://www.cdc.gov/hiv/basics/prep.html)

Education

STIMULANTS & FERTILITY/PREGNANCY
We did discuss some risks of stimulants with planned pregnancy. Current research does not conclusively show that stimulants significantly affect fertility.

Stimulant medications, such as those used for ADHD, can potentially increase the risk of certain complications. These might include a slightly increased risk of birth defects, preterm birth, or low birth weight. However, the overall risk is generally considered low. There's a potential risk of withdrawal or dependency in the newborn if the mother takes stimulant medication during pregnancy, although this risk is relatively low.

Often stopping the stimulant is the safest choice, however continued low-dose stimulants is sometimes chosen when absolutely necessary, with close communication with your OBGYN and Circle Medical.

LIFESTYLE MODIFICATIONS FOR HIGH CHOLESTEROL AND TRIGLYCERIDES
Dietary Changes:
• Reduce Saturated and Trans Fats: Limit red meat, butter, cheese, and processed foods.
• Increase Soluble Fiber: Eat more oats, beans, lentils, fruits, and vegetables.
• Eat Heart-Healthy Fats: Include olive oil, avocados, nuts, and fatty fish like salmon.
• Limit Sugar and Refined Carbohydrates: Avoid sugary drinks, sweets, and white bread.
• Moderate Alcohol Consumption: Too much alcohol can raise triglyceride levels.

Physical Activity:
• Aim for at least 150 minutes of moderate-intensity exercise per week, like brisk walking, cycling, or swimming.
• Include strength training exercises twice a week.

Weight Management:
• Losing weight can significantly lower cholesterol and triglyceride levels.
• Focus on sustainable, healthy weight loss methods, like balanced eating and regular exercise.

Other Tips:
• Smoking cessation improves your overall heart health and can positively impact your cholesterol and triglyceride levels.
Stress Management:
• Chronic stress can affect your cholesterol and triglycerides. Practice stress-reduction techniques such as meditation, yoga, or deep breathing exercises.

Monitoring and Follow-Up:
We will recheck your cholesterol and triglyceride levels in 6 months.
Maintaining these lifestyle changes is crucial for long-term health benefits.

Future Medication Consideration:
• If your cholesterol and triglyceride levels remain high despite these changes, we may consider medication like Vascepa. Vascepa is specifically used to lower high triglyceride levels.

Remember:
• Lifestyle modifications are not just about reducing numbers; they're about improving your overall health and quality of life.
• Making these changes can be challenging, but even small, incremental improvements can have significant health benefits.
• Please feel free to reach out if you have any questions or need support in making these lifestyle changes.

Sinusitis

We discussed your sinus symptoms and agreed that you have sinusitis - an acute infection of the upper respiratory system and sinus passages. Often this is viral, but we agreed to treat with antibiotics given your length and severity of symptoms.

We decided to prescribe an antibiotic for your sinusitis:
- Azithromycin 250gm, Take 2 tabs PO on day 1, then 1 tab PO daily until gone, #6, 0 refills
- Augmentin 875-125mg, Take 1 tab PO BID x 7 days, #14, 0 refills

We discussed over the counter options to help with your symptoms including:

Congestion:
- Dayquil can be taken as prescribed on the bottle, which usually has a decongestant like sudafed contained within it. This will help the pressure. 
- You can take OTC flonase (nasal steroid spray) to each nostril twice daily for the next 2 weeks or until your symptoms resolve

Pain and/or fevers:
- Tylenol 650mg every 4 hours OR Tylenol 1gm every 8 hours as needed
- Do not take ibuprofen or any other NSAID as you are severely allergic

Nasal discharge:
- Nyquil has benadryl in it, which can help dry up your passages and help you sleep better
- Netty pots: Nasal irrigation can help with nasal discharge and congestion as well. 
      - Mix 1/4 to 1/2 teaspoon of non-iodized salt (i.e. Kosher salt) into an 8oz cup of warm distilled or sterile water. Ensure the water is lukewarm and not too hot or too cold. Stir the mixture until the salt dissolves. Fill the Neti Pot with the solution. Stand over the sink or in the shower, and tilt your head slightly forward. Keep you mouth open. Gently inser tthe spout of the Neti pot into one nostril, and make sure it forms a good seal. Do not force it. Begin irrigating by tilting the Neti pot, allowing saline to flow into your nostril. It will pass through your nasal passages and exit through the other nostril. Do not breathe your your nose during the procedure. Switch nostrils once half the solution has been used.

Back Pain

_____ presenting to Circle Medical with back pain. 

Started: 
Trauma:
Timing: 
Aggravating factors:
Alleviating Factors: 
OTC Medications used:

Previous/similar episodes: 
Previous Treatments: 
Recent bacterial infections: 

Associated Symptoms:
• Fevers/chills: Denies
• Unintentional weight loss: 
• Numbness/tingling/weakness: Denies
• Loss of bowel/bladder function: Denies
• Saddle anesthesia: Negative

Lifestyle factors:
• PMHx: None
• Occupation: 
• Heavy lifting:
• IV drug use:

PDMP: reviewed on _____ in NJ/NY/PA, no records

We discussed your symptoms of back pain and agreed this is likely a temporary musculoskeletal strain. 

I have sent the following medications into your pharmacy:
- Naproxen 500mg, Take 1 tab PO every 12 hours PRN for pain, #30, 0 refills
- Cyclobenzaprine 10mg, Take 1 tab PO every 8 hours as needed for muscle spasms, #21, 0 refills

Cyclobenzaprine can make you sleepy, so don't drive or operate heavy machinery after taking it. 

We discussed followup with:
* Ortho: 
* Physical therapy: 
* Circle Medical: 

BACK PAIN EDUCATION:
Back pain is a common condition that affects many people at some point in their lives. It can range from a mild, dull ache to severe, debilitating pain. Understanding the causes, treatment options, and prevention strategies can help you manage back pain more effectively.

Self-Care for Back Pain:
• Rest: Avoid activities that worsen the pain, but try to stay as active as possible. Prolonged bed rest isn't recommended.
• Heat and Cold Therapy: Use ice packs for the first few days to reduce inflammation, then switch to heat to relax muscles and improve blood flow.
• Pain Relief: Over-the-counter pain relievers like ibuprofen or acetaminophen can help. Always follow the recommended dosage.

Exercise and Physical Activity:
• Stretching and Strengthening: Gentle exercises can strengthen the muscles of your back and abdomen.
• Low-Impact Aerobic Activities: Activities like walking or swimming can increase endurance and support your back.
• Posture Improvement: Practice good posture to reduce strain on your back.

Medical Treatments:
If your pain is severe or persists, medical treatments might include:
• Physical Therapy: Tailored exercise programs to improve posture, flexibility, and strength.
• Medications: Prescription pain relievers, muscle relaxants, or anti-inflammatory drugs.
• Injections: In some cases, cortisone injections may be recommended.

When to See a Doctor:
• If your back pain is severe and doesn’t improve with rest.
• If the pain spreads down one or both legs, especially if the pain extends below the knee.
• Causes weakness, numbness, or tingling in one or both legs.
• Is accompanied by unexplained weight loss.
• If you have a history of cancer, osteoporosis, steroid use, or drug/alcohol abuse.

Preventing Back Pain:
• Exercise Regularly: Focus on exercises that increase strength, flexibility, and endurance.
• Maintain a Healthy Weight: Being overweight strains back muscles. If you need to lose weight, talk with your doctor.
• Lift Properly: Lift using your legs and core, not your back. Avoid twisting.
• Ergonomics: Ensure a proper workstation setup if you work at a desk.

Anxiety/Depression

The patient is a _____________ here for anxiety/depression visit. 

Presenting symptoms: 

-- history of depression: 
-- history of anxiety: 
-- Medication trials (what worked, why did it not work?)-

-- Hospitalizations: Denies
-- Hx of past suicide attempts?: Denies
-- SI/HI: Denies
-- Psychotherapy: none currently
-- History of head injury: Denies
-- Current/past substance use: See below

PDMP: Reviewed ______ in NJ/NY, no records

Social history:
-- Living situation: 
-- Marital Status: 
-- Employed/Student: 
-- Educational Hx: 
-- Military Service:
-- Social support network: 
-- Exercise: 
-- Sleeping issues: 
-- Alcohol use: 
-- Life stressors: 

Goals of treatment: Improved mood

Measurement tools used and reviewed today: PHQ 9 and GAD 7

Today we discussed your mental health and wellness today.
 
Managing depression/anxiety is most effective through a multidisciplinary approach. This includes using medications as well as other evidence-based resources that have been shown to be as effective as medication when used and implemented correctly.
 
Given the extent of your symptoms at this time, we decided to start medications. I have sent the following medication to your pharmacy:
- Escitalopram 10mg, Take 1 tab PO daily, #15, 0 refills
- Fluoxetine 20mg, Take 1 capsule PO daily, #15, 0 refills
- Bupropion Hcl 150mg XL, Take 1 tab PO in AM x 4 days, then take 2 tabs PO in AM daily, #25, 0 refills
- Propranolol 20mg, Take 1 tab PO every 8 hours PRN for anxiety/panic, #30, 0 refills

We scheduled an appointment in 2 weeks for a followup. 

SSRI DRUG INFORMATION:
Escitalopram (Lexapro) is in a class of medications called Selective Serotonin Re-uptake Inhibitors. These increase serotonin levels in the brain to help treat anxiety and depression.

The medication is taken every day and is non-addictive. It does need to be taken every day, and usually does not help much with anxiety or depression for 4-6 weeks to take full effect. I recommend trying this medication for at least 6 months to see if it helps.

There are few side effects, which many get better with continued use. Common side effects include dizziness, upset stomach, or headaches. All SSRIs have the potential to decrease sexual interest or cause some erectile dysfunction. If this happens, please let me know.

If you develop any suicidal thoughts or severe anxiety or depression, please stop taking your medication and reach out to your family, go to a local ER, or call the national crisis line at 1-800-273-TALK (8255), OR text ‘TALK’ to 741741 to speak to trained counselors.
-------------------------------------------------------------------------------------
In addition to medication, I highly recommend psychotherapy. Psychotherapy is a general term for treating depression/anxiety by talking about your condition and related issues with a mental health professional. Psychotherapy is also known as talk therapy or psychological therapy. Different types of psychotherapy can be effective for depression/anxiety, such as cognitive behavioral therapy (CBT) or interpersonal therapy (IPT). Your mental health professional may also recommend other types of therapies. 

Psychotherapy can help you:
• Adjust to a crisis or other current difficulty
• Identify negative beliefs and behaviors and replace them with healthy, positive  ones
• Explore relationships and experiences, and develop positive interactions with others
• Find better ways to cope and solve problems
• Identify issues that contribute to your depression and change behaviors that make it worse
• Regain a sense of satisfaction and control in your life and help ease depression symptoms, such as hopelessness and anger
• Learn to set realistic goals for your life
• Develop the ability to tolerate and accept distress using healthier behaviors
 
There are websites which can be helpful in finding a therapist who is a good fit for you as well. Here are some examples:                                         
• Talk Space- https://www.talkspace.com/ 
• Better Help- https://www.betterhelp.com/
• Online-Therapy- https://www.online-therapy.com/
• Psychology Today https://www.psychologytoday.com/us/
• Pride Counseling- https://www.pridecounseling.com/

GERD / PUD

Today we discussed your acid reflux, abdominal discomfort, and nausea/vomiting. 

We discussed that this could be GERD or a stomach ulcer (peptic ulcer disease)

Gastroesophageal reflux disease (GERD) happens when acid from your stomach flows up into the esophagus. Decreased tone of the muscle that connects the stomach and the esophagus can lead to increased acid flow from the stomach to the esophagus. When acid comes in contact with the esophagus, the acid causes soreness (inflammation) in the esophagus. Over time, GERD may create small holes (ulcers) in the lining of the esophagus.

I have sent in the following medications for you:
- omeprazole (Prilosec) 40 mg tablet, take 1 tablet by mouth once daily at night, #15 tablets, with no refills
- Ondansetron 4mg, Take 1 tab orally and let dissolve every 6 hours PRN for nausea/vomiting, #30, 0 refills
- Famotidine 20mg, Take 1 tab PO BID, #30, 0 refills

Please do not start the Prilosec until you get the labs drawn below.  I have sent these to labcorp digitally, and we are checking:
- CBC
- CMP
- Lipids
- HbA1C
- H. Pylori breath test

FOODS TO AVOID:
Avoid foods and drinks that may decrease the tone of the muscle connecting your stomach to esophagus:
• Alcohol
• Caffeine
• Chocolate.
• Cow’s milk
• Peppermint or mint flavorings
• Garlic and onions
• Spicy foods
• Citrus fruits, such as oranges, lemons, or limes.
• Tea
• Tomato-based foods such as sauce, chili, salsa, and pizza
• Fried and fatty foods

MODIFIABLE LIFESTYLE CHANGES TO HELP:
There are modifiable lifestyle factors that can help decrease your reflux symptoms.
• Avoid lying down for the 3 hours prior to your bedtime or prior to taking a nap
• Eat small, frequent meals instead of large meals
• Wear loose-fitting clothing. Do not wear anything tight around your waist that causes pressure on your stomach
• Raise the head of your bed 6 to 8 inches with wood blocks to help you sleep. Extra pillows will not help
• Only take over-the-counter or prescription medicines for pain, discomfort, or fever as directed by your caregiver
• Do not take aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs)
• Quit smoking
• Stress management can help help reduce symptoms.
• Focus on weight loss

STRESS MANAGEMENT:
Here are some suggestions for stress management:
• Headspace: https://www.headspace.com
• Calm: https://www.calm.com
• Oprah&Deepak Meditation: https://chopracentermeditation.com
• You can also try a form of medical hypnosis by listening to the "Relieve Anxiety" app by Steven Gurgevich, PhD.
• Exercise is a great tool to manage stress. The "7 Minute Workout" app outlines a set of evidence-based exercises to help you boost metabolism and mood.

Additional resources about GERD:
-- https://www.asge.org/docs/default-source/about-asge/newsroom/doc-gerd_infographic_final.pdf
-- https://patient.gastro.org/gastroesophageal-reflux-disease-gerd/
-- https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults

SEEK IMMEDIATE MEDICAL CARE IF:
•       You have pain in your arms, neck, jaw, teeth, or back
•       Your pain increases or changes in intensity or duration
•       You develop nausea, vomiting, or sweating (diaphoresis)
•       You develop shortness of breath, or you faint
•       Your vomit is green, yellow, black, or looks like coffee grounds or blood
•       Your stool is red, bloody, or black

Insomnia

 It was a pleasure meeting you today, John Hurley Here is today's summary:

Insomnia is difficulty falling asleep, staying asleep, or early awakening and not being able to return to sleep. 

We agreed to trial OTC medications first, and then I am prescribing you Trazodone if those are ineffective. I recommend the following: 
- Take Melatonin 3-6mg 3-4 hours before you would like to go to bed (helps with sleep initiation)
- Take Magnesium Glycinate 1-2 capsules 1-2 hours before bed (helps with sleep maintenance)

I would try this for a week or so - if you notice no significant benefit, then instead I would take the prescription trazodone. I would start with 1/2 tablet for at least 3-4 days - increase to 1 full tablet if you feel like it is not helping much. I sent the following prescription to your pharmacy:
- Trazodone 50mg, Take 0.5-1 tab PO HS PRN for sleep, #15, 0 refills

We discussed that you do have a family history of sleep apnea, but you do not snore, so we will hold off on getting a sleep study for now. 

We scheduled a followup in 2 weeks. 

SLEEP HYGIENE RECOMMENDATIONS:
• Have a regular sleep schedule daily.
• Do not nap during the day.
• Sleep only as much as necessary to feel rested and then get out of bed.
• Exercise regularly, but not near bedtime.
• Do not spend more than 20 minutes lying in bed trying to fall asleep.
• Do not go to bed hungry.
• Avoid caffeinated beverages after lunch.
• Do not drink alcohol near bedtime.
• Do not smoke (especially during the evening).
• Ensure a comfortable bedroom environment before sleep ( minimize light, noise,  optimize temperature).
• Make a list of things to work on for the next day so anxiety is reduced at night.
• Minimize use of light producing screens such as phones or reading devices before bed. 

Relaxation therapy — this involves progressively relaxing your muscles from your head down to your feet.  There are many free apps that can help you do this:
• Insight Timer
• Simple Habit
• Buddify

Asthma

We discussed your upper respiratory symptoms and agreed you are having an asthma exacerbation. 

I have prescribed the following medications:
- Azithromycin 250gm, Take 2 tabs PO on day 1, then 1 tab PO daily until gone, #6, 0 refills
- Prednisone 50mg, Take 1 tab PO daily x 5 days, #5, 0 refills
- Albuterol HFA 90mcg/act, Inhale 2-4 puffs every 4-6 hours PRN for SOB/wheezing, #1, 2 refills
- Albuterol Sulfate 2.5mg/3ml, Inhale 2.5mg via nebulizer up to 4 times daily as needed, #1 box, 0 refills (30 nebulizer treatments)

We discussed that the antibiotic is most likely not needed, since you symptoms have only been going on for a few days and you don't have fevers. However, I sent this just in case your symptoms worsen, you develop high fevers, or if your symptoms persist longer than 10 days and you aren't getting better. 

We recommend you followup with your PCP and establish with a pulmonologist for your asthma. If needed/desired, you can establish with Circle Medical for primary care as well. 

ASTHMA EXACERBATION EDUCATION:
An asthma exacerbation, also known as an asthma attack, occurs when your asthma symptoms become more severe due to various triggers. During an attack, the airways in your lungs become inflamed and narrowed, making it hard to breathe.

Immediate Steps During an Exacerbation
1. Stay Calm: Panic can worsen asthma symptoms. Try to stay as calm as possible.
2. Use Your Quick-Relief Inhaler: Use your prescribed quick-relief (rescue) inhaler immediately. Typically, this is a short-acting beta-agonist like albuterol.
3. Follow the “Two Puff” Rule: Generally, you should take two puffs of your rescue inhaler, but follow the specific instructions given by your healthcare provider.
4. Sit Up Right: Don’t lie down. Sitting upright can make breathing easier.
5.Check Your Symptoms: If your symptoms do not improve after 20 minutes, you can take another dose of your rescue inhaler.

When to Seek Emergency Medical Help
• No Improvement: If symptoms don’t improve after using your rescue inhaler.
• Difficulty Speaking: Inability to complete sentences without gasping for breath.
• Blue Lips or Fingernails: This is a sign of severe oxygen deprivation.
• Extreme Difficulty Breathing: If you're struggling to breathe or experiencing severe wheezing and coughing.

Preventing Future Exacerbations
• Know Your Triggers: Common triggers include pollen, dust, smoke, and cold air. Avoid them as much as possible.
• Adherence to Medication: Take your long-term control medications as prescribed, even when you feel well.
• Regular Check-Ups: Keep up with regular asthma check-ups with your healthcare provider.
• Asthma Action Plan: Work with your healthcare provider to develop a personalized asthma action plan. This plan should detail your daily treatments, how to recognize and handle worsening asthma, and when to seek emergency care.

Lifestyle Modifications
• Exercise Regularly: Exercise can strengthen your respiratory system, but consult your healthcare provider about suitable activities.
• Quit Smoking: Smoking can exacerbate asthma symptoms.
• Healthy Diet: A balanced diet can help manage asthma.

DERM

I suspect this is a condition called Keratosis Pilaris. For this, I recommend the following products:

1. A moisturizer with 2% salicylic acid it in, plus at least 20% urea cream. I recommend this product on Amazon: https://tinyurl.com/2e9e2bzz

2. You can place the Tretinoin that I prescribed for your face on the skin as well, which can help.

3. Get a good Body moisturizer as well, like a tub of Cerave body moisturizer. The Driest areas can benefit from placing Aquafor on those afterwards.

I prescribed an OTC medicated shampoo that is typically used for dandruff. YOu can apply this to your face in the shower and leave sit after lathering it in for 2-3 minutes, then wash it off with warm water. Do this 1-2 times per week to start. If it causes any worsening irritation, stop it and let me know. The pharmacy may fill this, or you may need to grab it from the shampoo section. 
- Selsun Blue 1% medicated Shampoo, Apply thin layer to face and let sit for 2-3 minutes then rinse off; do this 1-2x/week, #1 bottle, 0 refills

-MY RECOMMENDED FACIAL REGIMEN-
Do these steps in the correct order as well, allowing your skin to dry between steps. 

MORNING:
• Vitamin C serum (to help improve complexion and remove redness): https://tinyurl.com/2d5kbeb8 or something similar
• Moisturizer (to help keep hydrated and smooth): CeraVe facial moisturizer is pretty good
• Sunscreen with at least 15 SPF (to help prevent sun damage): any sunscreen should work, as long as at least 15-30 SPF

EVENING:
• Gentle Cleanser: CervaVe Gentle Cleanser like https://tinyurl.com/3r79p65s
• Retinol: (prescription) Tretinoin 0.025% 1-3 times per week as tolerated. If you have redness/irritation the next day, skip that next evening. 
• Moisturizer (to help keep hydrated and smooth): Same as above

We booked a followup appointment in 1 month!

OSA

Patient name, DOB, and address verified and confirmed to be located in a state in which the provider is licensed. 

The patient gives verbal consent to receive healthcare services via video for this encounter.  The patient was informed that video visits are performed using real-time telehealth tools, including a live video connection and sometimes an in-person visit may be needed to fully evaluate them.
__________________________________________________________________________________________

____________ here for sleep apnea evaluation.

General symptoms: 

Other histories:
–Ever been diagnosed with sleep apnea in the past? Denies
–Has had/used a CPAP in the past? Denies
–Failed a CPAP in the past? Denies
–Family history of sleep apnea? Denies
–history of sleep study in the past? When? Result? Denies
–Is there an underlying medical issue keeping the patient up at night? Denies

-History of excessive daytime sleepiness, mood disorder, hypertension, stroke, insomnia, ischemic heart disease? Denies
–Psych history (Anxiety or depression symptoms that could be contributing to decreased sleep) Denies
–Insomnia history: Denies
–History of RLS?: Denies
–If concerned for narcolepsy: No concern
–Are they taking any medications that could be keeping them up? None
–Substance use (coffee, alcohol, cigarettes) See below
-- Current illicit drug use? Denies
–PCP? See above
–Last blood work? 

-PDMP reviewed? No records

Stop Bang (Conduct this questionnaire if you think your patient may have sleep apnea): (Score 1 point for each positive response):
-Do you snore loudly (loud enough to be heard through closed doors or your bed partner elbows you for snoring at night)?
-Do you often feel tired, fatigued, or sleepy during the daytime (example: falling asleep while driving)?
-Has anyone observed you stop breathing or choking/gasping during your sleep? 
-Do you have or are you treated for high blood pressure?
-BMI more than 35Kg/m2?
-Age over 50 years?
-Neck circumference > 40 cm?
-Gender male?
SCORE = 
Scoring: 0-2 low risk, 3-4 intermediate risk, 5 or more high risk (Sleep study/labs)

Epworth Sleepiness Scale (ESS)  (Conduct this questionnaire if you think your patient may have sleep apnea)
What is you chance of dozing from a scale of 0-3 in the following situations:(0-would never doze, 1-slight chance of dozing, 2- moderate chance of dozing, 3- high chance)
-Sitting and reading
-Watching T.V.
-Sitting inactive in a public place (theater)
-As a passenger in a car for an hour without a break
-Lying down to rest in the afternoon
-Sitting and talking to someone
-Sitting quietly after lunch (when you’ve had no alcohol)
-In a car, while stopped in traffic 
SCORE = 
A total score of 10 points or higher shows possible increased risk for obstructive sleep apnea (sleep study/labs). 

Are you ordering an at-home sleep study for this patient (Yes/No)? Yes
If so, will this be an at home sleep study on: (room air, with oxygen, with oral appliance, or with CPAP)?  ROOM AIR
Have you CONFIRMED SHIPPING ADDRESS (Yes/No) ? YES

 It was a pleasure meeting you today, Justin Williams. Here is today's summary:

We discussed that your symptoms are consistent with possible sleep apnea, and that you would benefit from an at home sleep study. We discussed the following plan:

An order will be placed for an at home sleep study device for a 2 night (back to back) at home sleep study while on ROOM AIR.

Today I have CONFIRMED your shipping address for your at home sleep study device.

You will receive a message from the Circle Medical team with the estimated out of pocket cost associated with your at home sleep study device and interpretation. If you do not hear back within 5 business days, please send a chat. 

You will also be sent a patient responsibility form to review and sign. Once a signature is collected, we will order your at home sleep study device.

The at home sleep study device is NOT disposable and will need to be mailed back within 30 days of receiving your at-home sleep study device in the mail.

Your provider will receive your sleep study results, along with a customized list of recommendations from a board certified Sleep Specialist, who reviews your results, within 72 business hours of you completing your at home sleep study.

Then you will follow up with your Circle Medical provider to review your sleep study results and to discuss next steps.

For more information about your at home sleep study, please see our website https://www.circlemedical.com/what-we-treat/sleep-study

We will review these results with you at our next follow up appointment in 4 weeks.

If you have questions please reach out to Circle Medical via chat.

Thank you for choosing Circle Medical!

Letters

ADHD

To Whom It May Concern,

I am writing to verify that the patient referenced in this communication is under the care of our clinic.

Diagnosis: F90.2, Attention-deficit hyperactivity disorder, combined type.
Date of Evaluation: 
Date of Last Visit: 
Scheduled Next Visit: 

I would like to additionally confirm that this patient is currently on a treatment plan that includes medication for their ADHD. It is important to note that the prescribed medication effectively manages the symptoms associated with their condition. 

They are most recently prescribed:
- 

As a result of this treatment, the patient exhibits stable and controlled behavior, which is essential for their day-to-day activities and professional responsibilities. In my professional medical opinion, the patient is fully capable of performing their duties in a work environment, including ________. The treatment does not impose any restrictions on their ability to safely and effectively
fulfill job-related tasks. 

Their condition, under the current treatment regimen, does not impair their cognitive abilities or judgment skills, which are crucial in high responsibility workplaces such as a nuclear power plant. Please be assured that the patient's ADHD, with the ongoing treatment, poses no limitations or risks in a professional setting, including roles that require high levels of concentration, attention to detail, and adherence to safety protocols. 

Should you require any further information or clarification regarding the patient's health status and their fitness for work, please do not hesitate to contact me.

GAHT

Dear Surgeon,

____________ is a patient in my care at Circle Medical. They have been a patient here since ________. They identify as __________ and use _______ pronouns. They note that they first knew their gender identity differed from their assigned sex ___ years ago. They have socially transitioned by __________________. They have been successfully and consistently living in a gender role congruent with their affirmed gender since _______. They have been consistently on hormone therapy since _________ (If not yet started, or if contraindicated or chosen not to take hormones, state that here). 

Despite these interventions, they report significant anxiety, depression, and distress due to their experience of dysphoria. By my independent evaluation of __________, I have diagnosed them with Gender Dysphoria (ICD-10 F64.9).  They have expressed a persistent desire for ____[surgery]_____. Their goals of surgery are _______. Surgery will address their gender dysphoria in these ways: _____________.

__________ is physically healthy to undergo this surgery. They are healthy without any medical comorbidities [list them if not true]. Their current medications include ________.  Their surgical history includes ________.  They are stably housed and have prepared for their post-op recovery (if this is true, if not, state plan for post-op recovery).  They have no issues with illicit drug use or abuse (if this is true, if not, explain plan of care for stabilization).

_____________ has more than met the WPATH criteria for ________ surgery. They are capable of making an informed decision about undertaking surgery. I believe that the next appropriate step for them is to undergo [surgery], and I believe this will help them make significant progress in further treating their gender dypshoria. Therefore, I hereby recommend and refer _____________ to have this surgery.
If you have any questions or concerns please do not hesitate to contact myself or my office.
 
Sincerely,
 
William J. Kelly, FNP-C
Family Nurse Practitioner
License #:

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