26 July 2024 Dr. Chong 123 Medical Centre 456 Health Street Sydney NSW 2000 Dear Dr Chong, Re: John Doe DOB: 15/03/1985 ph: 0412 345 678 Address: 789 Patient Road, Sydney NSW 2000 Problem List: • Major Depressive Disorder, recurrent, moderate • Generalised Anxiety Disorder • Insomnia • Hypertension Medications: • Sertraline 100mg daily • Propranolol 40mg twice daily • Temazepam 10mg nocte PRN Allergies: No known allergies Past Psychiatric Treatment History: First depressive episode at age 25, treated with fluoxetine for 6 months. Recurrence at age 32, treated with cognitive behavioural therapy and sertraline. No psychiatric hospitalisations. Family Psychiatric History: Mother diagnosed with bipolar disorder. Paternal uncle with history of alcohol use disorder. Family Medical History: Father with type 2 diabetes and coronary artery disease. Maternal grandmother with breast cancer. Substance Use History: Non-smoker. Alcohol intake 2-3 standard drinks per week. No illicit drug use. Past cannabis use in university, ceased 10 years ago. Forensic History: No significant forensic history Thank you for referring John Doe for psychiatric assessment regarding worsening depressive symptoms and anxiety. Mental State Examination: 39-year-old male, well-groomed, appeared older than stated age. Maintained good eye contact. Psychomotor retardation noted. Mood subjectively low, affect constricted. Speech slow in rate and monotonous. Thought process logical and goal-directed. No evidence of thought disorder or perceptual disturbances. Denied suicidal ideation. Cognitively intact. Limited insight into severity of depressive symptoms. Impression: Overall, it was my impression that John meets criteria for Major Depressive Disorder, recurrent episode, moderate severity, with comorbid Generalised Anxiety Disorder. Current psychosocial stressors including work pressures and relationship difficulties appear to have exacerbated his symptoms. No acute safety concerns identified. Treatment Recommendations: Increase sertraline to 150mg daily. Refer for cognitive behavioural therapy focusing on depression and anxiety management. Consider adding mirtazapine 15mg nocte for insomnia if sleep does not improve with sertraline increase. Review in 4 weeks to assess response. Encourage regular exercise and sleep hygiene practices. Yours sincerely, Dr. Sarah Johnson Consultant Psychiatrist MBBS, FRANZCP Provider No: 1234567A

I saw Zoe Adams again today on 15th May 2023 accompanied by her mother. As you are aware, Zoe has a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), predominantly inattentive type. Recent assessments indicate a potential comorbid anxiety disorder, which we are monitoring closely. On the whole, I am extremely pleased with Zoe's progress. Her concentration has improved significantly, particularly in school settings. However, some challenges persist in social interactions, possibly related to emerging anxiety symptoms. We discussed implementing cognitive behavioral strategies to address Zoe's anxiety. I've provided her family with resources on relaxation techniques and mindfulness exercises suitable for adolescents. Zoe remains on Methylphenidate 30mg once daily, which has been effective in managing her ADHD symptoms. We're considering adding a low dose of Sertraline to address the anxiety, pending further evaluation. I plan to see Zoe again in 6 weeks to reassess her progress and decide on potential anxiety medication. In the meantime, please monitor for any adverse effects from her current medication regimen. If you have any concerns, please don't hesitate to contact me on 0412 345 678.

CHRONIC DISEASE MANAGEMENT GP Management Plan Review: MBS Item 732 Patient's Name: Mr John Doe Date of Birth: 15/06/1965 Contact Details: 123 Main Street, Suburbia, NSW 2000 Home Phone: 02 9876 5432 Work Phone: 02 8765 4321 Mobile Phone: 0412 345 678 Medicare No.: 2345 67890 1 Details of Patient's Usual GP: Dr Chong 123 Medical Centre 456 Health Street, Suburbia, NSW 2000 Details of Patient's Carer (if applicable): Not applicable If the patient has a previous or existing care plan, when was it prepared and what were the outcomes?: On: 15/03/2023 By: Dr Chong Other notes or comments relevant to the patient's care planning: Patient has shown improvement in blood pressure control but struggles with medication adherence Medications: Perindopril 5 mg tablet, one daily Metformin 500 mg tablet, one twice daily Atorvastatin 20 mg tablet, one at night Allergies: Penicillin I have explained the steps and costs involved, and the patient has agreed to proceed with the service: GP Signature: _________________ Date: __________ GP MANAGEMENT PLAN Patient problems / needs / relevant conditions: Type 2 diabetes mellitus Hypertension Hyperlipidaemia Goals - changes to be achieved: Improve glycaemic control Maintain blood pressure below 130/80 mmHg Reduce LDL cholesterol to <2.0 mmol/L Required treatments and services: Task Provider Due HbA1c test Dr Chong 15/09/2023 Lipid profile Dr Chong 15/09/2023 Dietitian review Ms Smith 30/09/2023 Arrangements for treatments/services: Provider Phone Fax Dr Chong 02 9876 5432 02 9876 5433 Ms Smith 02 8765 4321 02 8765 4322 Copy of GPMP offered to patient?: Yes Copy / relevant parts of the GPMP supplied to other providers?: Yes GPMP added to the patient's records?: Yes Date service was completed: 15/06/2023 Review Date: 15/12/2023 CHRONIC DISEASE MANAGEMENT Team Care Arrangement Review: MBS Item 732 TEAM CARE ARRANGEMENTS Copy of TCA offered to patient?: Yes Copy / relevant parts of the TCA supplied to other providers?: Yes TCA added to the patient's records?: Yes Referral forms for Medicare allied health and dental care services completed?: Yes