Unit 5-Psychiatric Mental Health Assessment of a Child-Adolescent. 1000w. 4 references. Due 10-3-24. Must use the template and example provided. Must use the attachment.

Criteria

Clinical Notes

Informed Consent

Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risks and benefits.

Subjective

Verify Patient

Name: J. W.

DOB: 05/15/1995

Minor:

Accompanied by:

Demographic: African American female

Gender Identifier Note: Female

CC: "I'm here for my ADHD follow-up. The medication is helping, but I'm still having some issues."

HPI: Jane is a 28-year-old female who was diagnosed with ADHD-Combined Type 3 months ago. She started on Adderall XR 20mg daily. She reports improvement in focus and task completion at work but still struggles with time management and organization at home. She has been using a planner as suggested but finds it difficult to maintain consistently.

Pertinent history in record and from patient: No changes since last visit. Continues to work as a graphic designer. Lives alone with her cat. Single, no children.

During assessment: Patient describes her mood as "mostly good, but sometimes frustrated."

Mood and Associated Symptoms:

· Patient describes her mood as "mostly good"

· Self-esteem appears fair

· No reported feelings of excessive guilt

· No reported anhedonia

· Does not report sleep disturbance

· Does not report change in appetite

· Does not report libido disturbances

· Does not report change in energy

· No reported changes in concentration or memory outside of ADHD symptoms

Other Psychiatric Symptoms:

· Does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria

· Does not report excessive fears, worries or panic attacks

· Does not report hallucinations, delusions, obsessions or compulsions

· Does not report symptoms of eating disorder

· No recent weight loss or gain

· Does not report symptoms of a characterological nature

SI/ HI/ AV: Patient denies current suicidal ideation, homicidal ideation, and auditory/visual hallucinations.

Allergies: NKDFA

(medication & food)

Past Medical Hx:

Medical history: Migraines (controlled with OTC medication)

Past Psychiatric Hx:

Previous psychiatric diagnoses: ADHD (current), no other psychiatric diagnoses

Current Medications:

· Adderall XR 20mg daily

· Multivitamin daily

· PRN Ibuprofen for migraines

Safety concerns:

History of Violence to Self: None reported

History of Violence t o Others: none reported

Auditory Hallucinations: None reported

Visual Hallucinations: None reported

Mental health treatment history discussed:

History of outpatient treatment: not reported

Previous psychiatric hospitalizations: not reported

Prior substance abuse treatment: not reported

Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events.

Substance Use:

· Client denies use or dependence on nicotine/tobacco products.

· Client does not report abuse of or dependence on alcohol and other illicit drugs.

Current Medications:

· Adderall XR 20mg daily

· Multivitamin daily

· PRN Ibuprofen for migraines

Past Psych Med Trials: None reported

Family Medical Hx: No hx of chronic illness

Family Psychiatric Hx:

Substance use

Suicides

Mother with suspected undiagnosed ADHD

Developmental diagnoses

Social History:

· Occupation: Graphic designer, full-time

· Education: Bachelor's degree in Fine Arts

· Substance use: Denies current use of alcohol or illicit substances

· Exercise: Reports regular exercise routine

ROS:

Constitutional: No report of fever or weight loss.

Eyes: No report of acute vision changes or eye pain.

ENT: No report of hearing changes or difficulty swallowing.

Cardiac: No report of chest pain, edema or orthopnea.

Respiratory: Denies dyspnea, cough or wheeze.

GI: No report of abdominal pain.

GU: No report of dysuria or hematuria.

Musculoskeletal: No report of joint pain or swelling.

Skin: No report of rash, lesion, abrasions.

Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia.

Hematologic: No report of blood clots or easy bleeding.

Allergy: No report of hives or allergic reaction.

Reproductive: No report of significant issues.

Verify Patient: Name, Assigned  identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.

Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.

HPI:

, Past Medical and Psychiatric History,

Current Medications, Previous Psych Med trials,

Allergies.

Social History, Family History.

Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”

Objective

Vital Signs: Stable

This is where the “facts” are located.

Vitals,

**Physical Exam (if performed, will not be performed every visit in every setting)

Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

DSM5 Diagnosis: with ICD-10 codes

F90.2 Attention-Deficit/Hyperactivity Disorder, Combined Presentation

Jane continues to meet criteria for ADHD-Combined Type. While she has shown improvement with medication, she still experiences significant symptoms, particularly in home life organization. No current evidence of comorbid mood, anxiety, psychotic, or eating disorders.

Patient has the ability/capacity to respond to psychiatric medications/psychotherapy and appears to understand the need for treatment. She is willing to maintain adherence.

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Informed Consent Ability

Plan

(Note some items may only be applicable in the inpatient environment)

Inpatient:

Medications:

· Continue Adderall XR 20mg daily

· Discuss potential strategies for improving effectiveness of current dose

Psychotherapy:

· Refer to behavioral therapy CBT focusing on organizational skills and time management 3 times per week.

· Educate on meditation-based therapies such as mindfulness, vipassana, and yoga to increase focus.

· Provide resources for ADHD coaching.

Lifestyle modifications:

· Encourage continuation of current exercise routine

· Suggest implementing mindfulness techniques to improve focus

Education:

· Reviewed ADHD symptoms and management strategies

· Discussed importance of consistent medication use and follow-up appointments

· Provided information on ADHD support groups in the area

Follow-up:

· Schedule next appointment in 4 weeks

· Patient instructed to call if symptoms worsen or side effects occur

Lab work:

· Basic metabolic panel and liver function tests to be completed before next visit

· Slightly elevated liver enzymes noted, likely due to Adderall use. Will monitor closely.

50% of time spent in counseling and coordination of care

Time spent in Psychotherapy 45 minutes

Visit lasted 45 minutes

Billing Codes for visit:

99214 - Office or other outpatient visit for the evaluation and management of an established patient

90833 - Psychotherapy, 30 minutes with patient when performed with an evaluation and management service 96127 - Brief emotional/behavioral assessment

____________________________________________

NAME, TITLE:

Date: September 9, 2024 Time: 2. 30PM