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Issues addressed in GPMP • Type 2 Diabetes Mellitus • Hypertension • Hyperlipidemia • Obesity • Osteoarthritis (knee) Current Medications Metformin 1000mg BD for diabetes. Ramipril 5mg OD for hypertension. Atorvastatin 20mg OD for hyperlipidemia. Paracetamol 1g QID PRN for osteoarthritis pain. Update of Health Issues • Type 2 Diabetes: HbA1c improved from 7.8% to 7.2%. • Hypertension: BP stable at 138/82 mmHg. • Hyperlipidemia: LDL-C reduced to 2.8 mmol/L. • Obesity: BMI decreased from 32 to 30.5 kg/m². • Osteoarthritis: Pain score reduced from 7/10 to 5/10. Goals • Type 2 Diabetes: Achieve HbA1c ≤ 7.0% within 6 months. • Hypertension: Maintain BP < 130/80 mmHg. • Hyperlipidemia: Reach LDL-C < 2.5 mmol/L in 3 months. • Obesity: Reduce BMI to < 30 kg/m² in 6 months. • Osteoarthritis: Maintain pain score ≤ 4/10. For Medication Review (DDMR)

Dear Dr. Emily Thompson, Thank you for agreeing to see Mrs. Sarah Johnson under the Better Access Scheme for six sessions. Your expertise in managing her current mental health concerns is greatly appreciated. Please find enclosed the Mental Health Care Plan for your review. If you require any further information or have any questions, please don't hesitate to contact me. I look forward to your assessment and recommendations for Mrs. Johnson's ongoing care. Sincerely, Dr. Michael Roberts [Signature space] Patient Problem/s • Major Depressive Disorder, Recurrent, Moderate (DSM-5: 296.32) • Generalized Anxiety Disorder (DSM-5: 300.02) Background to the current problems Mrs. Johnson, a 42-year-old female, presents with a 6-month history of worsening depressive symptoms and anxiety. She reports persistent low mood, anhedonia, fatigue, and difficulty concentrating, which have significantly impacted her daily functioning. Previous treatments include a trial of sertraline 50mg daily for 3 months, which provided minimal relief. Currently, she is taking escitalopram 10mg daily, prescribed 4 weeks ago, and attending weekly mindfulness classes. No previous psychological interventions have been attempted. Social History Mrs. Johnson is married with two children aged 10 and 12. She denies smoking or illicit drug use but reports occasional alcohol consumption (2-3 glasses of wine per week). Previously employed as a high school teacher, she is currently on leave due to her mental health concerns. Mrs. Johnson is of Caucasian descent and was born and raised in Australia. She describes a supportive family environment but feels increasingly isolated due to her symptoms. Mental State Examination • Appearance: Well-groomed, appropriate attire • Behavior: Cooperative, mildly psychomotor retarded • Speech: Normal rate and volume, slightly monotonous • Mood: Depressed • Affect: Restricted, congruent with mood • Thought form: Logical and coherent • Thought content: No delusions or obsessions noted • Perception: No hallucinations reported • Cognition: Alert and oriented, intact memory • Insight: Good • Judgment: Intact • Risk assessment: Low risk of self-harm, no suicidal ideation • Key family contact: Mr. David Johnson (husband) - 0412 345 678 Formulation Mrs. Johnson's presentation is consistent with Major Depressive Disorder and Generalized Anxiety Disorder, likely exacerbated by work-related stress and difficulty balancing family responsibilities. Her current treatment includes medication management by myself and weekly mindfulness classes. Patient education has been provided regarding the nature of depression and anxiety, the importance of adherence to medication, and the potential benefits of psychological interventions. Expectations and Concerns 1. Problem: Major Depressive Disorder and Generalized Anxiety Disorder 2. Goals: Reduce depressive symptoms, manage anxiety, improve daily functioning 3. Action/Tasks: Engage in Cognitive Behavioral Therapy, continue medication as prescribed 4. Emergency care/relapse prevention: Crisis plan discussed, including contact numbers for mental health crisis team 5. Initial action plan: Weekly therapy sessions, medication review in 4 weeks 6. Patient consent: Mrs. Johnson has provided verbal consent for this referral and sharing of information Referring GP Details Dr. Michael Roberts, MBBS, FRACGP, Greenwood Medical Centre, 123 Main Street, Sydney, NSW 2000. Phone: (02) 9876 5432. Fax: (02) 9876 5433. Provider Number: 1234567A.

John Smith, born on 15/03/1976 (47 years old), is married with two children aged 12 and 9. He works as a software engineer for a tech company in the city. Mr. Smith lives with his family in a suburban area and commutes to work daily. He maintains an active lifestyle, regularly participating in weekend sports activities with his children. • Current medications: Lisinopril 10mg daily for hypertension • Allergies: Penicillin (rash) • Recent vaccinations: Influenza vaccine (3 months ago) • Smoking: Non-smoker • Alcohol consumption: 2-3 standard drinks per week, usually on weekends • Hypertension diagnosed 2 years ago, well-controlled with medication • Appendectomy at age 15 • Fractured left wrist from a cycling accident 5 years ago, fully healed • Father: Type 2 diabetes diagnosed at age 60 • Mother: Breast cancer at age 55, in remission • Maternal grandmother: Osteoarthritis Mr. Smith's overall health status is generally good. He maintains a healthy weight, exercises regularly, and manages his hypertension effectively with medication. However, there are concerns about his family history of diabetes and cancer. We discussed the importance of regular check-ups, maintaining a healthy lifestyle, and being vigilant about early signs of these conditions. Mr. Smith expressed understanding and commitment to following preventive measures. • Blood pressure: 125/80 mmHg (within normal range) • BMI: 24.5 (normal weight) • Fasting blood glucose: 5.2 mmol/L (normal) • Total cholesterol: 4.8 mmol/L (within normal range) 1. Asthma: Low risk. No personal or family history. No action required. 2. Cardiovascular illness: Moderate risk due to hypertension and family history of diabetes. Action: Continue blood pressure medication and monitoring. 3. Diabetes: Moderate risk due to family history. Action: Annual blood glucose testing and lifestyle counseling. 4. Mental health: Low risk. No personal or family history. Continue monitoring during regular check-ups. 5. Arthritis: Low to moderate risk due to family history. Action: Maintain healthy weight and exercise regimen. 1. Smoking: Non-smoker. No intervention required. 2. Nutrition: Generally good. Advised to increase fruit and vegetable intake. 3. Alcohol: Low risk. Consumption within recommended limits. 4. Physical activity: Adequate. Encouraged to maintain current exercise routine. 5. Mood: No concerns. Appears to manage stress well through regular exercise and family activities. 1. Blood pressure: Well-controlled with medication. Continue monitoring. 2. Body weight: Normal BMI. Advised to maintain current weight. 3. Cholesterol: Within normal range. Recheck in 2 years. 4. Glucose metabolism: Normal. Annual testing recommended due to family history of diabetes. • Fasting lipid profile: To be scheduled in 2 years • Fasting blood glucose: Annual testing • Prostate-specific antigen (PSA) test: To be considered at age 50 or earlier if family history changes Mr. Smith was advised to maintain his current healthy lifestyle, including regular exercise and a balanced diet. We discussed the importance of stress management techniques and maintaining work-life balance. He was encouraged to continue his blood pressure medication as prescribed and attend annual check-ups to monitor his risk factors, particularly for diabetes and cardiovascular disease. Mr. Smith agreed to schedule a follow-up appointment in 12 months for reassessment and to discuss any new health concerns that may arise.

Dear Dr. Johnson, I am writing to refer Mrs. Emily Thompson, a 32-year-old primigravida, for antenatal care. Mrs. Thompson has recently confirmed her pregnancy and requires comprehensive prenatal management. Given her medical history and current pregnancy status, I believe she would benefit from your expertise in obstetrics. Please find below the relevant patient information and medical details to assist in her care. Patient Information • Name: Emily Thompson • Date of Birth: 15/09/1991 • Address: 123 Maple Street, Riverdale, NY 10463 • Contact Number: (718) 555-1234 Current Pregnancy • LMP: 03/01/2023 • EDD: 10/08/2023 • Ultrasound findings: Viable intrauterine pregnancy, CRL consistent with 8 weeks gestation Obstetric History • G1P0 • No previous pregnancies or miscarriages Medical History • Mild asthma, well-controlled • Appendectomy (2015) • Allergic to penicillin Family History • Maternal: Hypertension • Paternal: Type 2 diabetes Medications • Albuterol inhaler (as needed) • Prenatal vitamins Social and Demographic Data • Occupation: Elementary school teacher • Non-smoker • No alcohol consumption since pregnancy confirmation • No recreational drug use Mrs. Thompson has undergone initial blood work, including a complete blood count, blood type, and Rh factor. Her pap smear is up to date, performed six months ago with normal results. I have also requested routine first-trimester screening tests, including HIV, hepatitis B, and rubella antibody titers. Thank you for accepting this referral. Please do not hesitate to contact me if you require any additional information or have any concerns regarding Mrs. Thompson's care.

Mental Health Treatment Plan The patient, Sarah Thompson, has provided informed consent for this mental health care plan and agrees to share it with her psychologist, Dr. Emily Chen. Background Sarah Thompson is a 28-year-old female with a history of anxiety and depression since her late teens. She had her first mental health review with her GP at age 19, which resulted in a referral to a psychologist. Sarah attended six sessions of cognitive-behavioral therapy (CBT) but discontinued due to financial constraints. She has never been admitted to a mental health unit. Sarah was prescribed sertraline 50mg daily for depression two years ago by her previous GP but stopped taking it after three months due to side effects. No other relevant medical history was reported. Current Mental Health Issues Sarah presents with symptoms of persistent low mood, fatigue, and difficulty concentrating, which have worsened over the past six months. She reports frequent worry about her job performance and social interactions, leading to avoidance behaviors. Sarah also experiences occasional panic attacks, characterized by heart palpitations, sweating, and a sense of impending doom. These symptoms have significantly impacted her daily functioning and quality of life. Screen for mental health conditions Sarah's symptoms are consistent with major depressive disorder and generalized anxiety disorder. There is no evidence of bipolar disorder, psychosis, or eating disorders based on the current assessment. Social history Childhood: Generally happy childhood, no significant trauma or abuse reported. Grew up in a suburban area with both parents and a younger sister. Home life: Currently lives alone in a small apartment in the city. Education: Bachelor's degree in Marketing. No reported issues during her education. Employment: Works as a marketing coordinator for a medium-sized company. Recently feeling overwhelmed and anxious about job performance. Lifestyle: Non-smoker, occasional alcohol use (1-2 drinks per week), no illicit drug use. Inconsistent exercise routine. Relationships/sexuality: Single, ended a 3-year relationship 8 months ago. Reports difficulty forming new relationships due to anxiety. MSE Appearance: Well-groomed, appropriately dressed Behavior: Cooperative, maintained good eye contact, occasionally fidgety Speech: Normal rate and volume, coherent Mood: "Anxious and down" Affect: Congruent with mood, restricted range Thoughts: Logical and goal-directed, no evidence of thought disorder Perception: No hallucinations or delusions reported or observed Insight: Good insight into her mental health issues Judgement: Intact Suicidal thoughts: Denies current suicidal ideation or intent Cognition: Alert and oriented, no apparent cognitive deficits Formulation Predisposing factors: - Family history of anxiety (mother) - Perfectionist tendencies developed in childhood Precipitating factors: - Recent job promotion with increased responsibilities - End of long-term relationship 8 months ago Perpetuating factors: - Social isolation due to avoidance behaviors - Negative self-talk and catastrophic thinking - Poor sleep hygiene Protective factors: - Good insight into her condition - Supportive family - Motivation to improve mental health - Stable employment Impression Sarah presents with symptoms consistent with major depressive disorder and generalized anxiety disorder. Her anxiety appears to be significantly impacting her daily functioning and contributing to her depressive symptoms. Differential diagnoses to consider include adjustment disorder with mixed anxiety and depressed mood, given the recent life changes. Assessment tool DASS-21 scores: Depression: 24 (Severe) Anxiety: 18 (Severe) Stress: 28 (Severe) Risk assessment Suicide: Low risk. No current suicidal ideation, intent, or plan. No history of suicide attempts. Homicide: No risk. No homicidal ideation or intent reported. Self-harm: Low risk. No current self-harm behaviors or intentions reported. Goals 1. Reduce symptoms of depression and anxiety - Refer to psychologist for CBT, focusing on challenging negative thoughts and developing coping strategies - Consider reintroduction of antidepressant medication (SSRI) after discussing options and potential side effects 2. Improve social connections and reduce avoidance behaviors - Gradually increase social interactions through exposure therapy techniques - Join a local support group for individuals with anxiety and depression 3. Enhance work-life balance and stress management - Implement time management and prioritization strategies - Practice mindfulness and relaxation techniques daily Plan Referrals: 1. Psychologist: Dr. Emily Chen for CBT, 6-8 sessions initially 2. Psychiatrist: Dr. Mark Johnson for medication evaluation and management Psychoeducation on depression, anxiety, and the importance of self-care provided during the consultation. Emergency care: Lifeline 13 11 14 : Mental Health Access Line 1800 011 511 Psycho-education performed: Yes Patient agreement to goals: Yes Copy of plan given to patient: Yes Review Date: Patient is scheduled for a follow-up consultation in 4 weeks for reassessment and review of the mental health care plan. Crisis plan 1. Recognize early warning signs of worsening symptoms (e.g., increased isolation, persistent negative thoughts) 2. Utilize learned coping strategies (deep breathing, progressive muscle relaxation) 3. Reach out to a trusted friend or family member for support 4. Contact psychologist or GP if symptoms persist or worsen 5. In case of emergency or suicidal thoughts, call Lifeline (13 11 14) or go to the nearest emergency department 6. Keep a list of emergency contacts readily available, including healthcare providers and support persons

Diagnosis Left ankle bimalleolar fracture with syndesmotic injury. Operation Open reduction and internal fixation of left ankle performed (Thursday, 15 June 2023). Plan 1. Non-weight bearing for 6 weeks 2. Follow-up appointment in 2 weeks 3. Physiotherapy referral after 6 weeks GP Action Arrange removal of sutures in 10-14 days. Dear Dr. {Doctor's Name}, Today at {Hospital Name}, I performed the above procedure on Sarah Johnson under a general anaesthetic. Intra-operatively, I achieved anatomical reduction and fixation of both malleoli. Syndesmotic screw was placed to address the syndesmotic injury. Sarah Johnson had an uneventful post-op recovery. She will be discharged today with pain medication, a medical certificate, and post-operative care instructions. Yours faithfully,