Assgn

Meditrek Note

Name: J. C.

Age: 40yrs

Purpose of Note: Initial psychiatric evaluation

Chief complaint: Severe inattentiveness interfering with occupational functioning.

Diagnosis: F90.2 - Attention-deficit hyperactivity disorder, combined type.

Medical/Physical Disorders: None Psychosocial Stressors (formerly Axis IV):

Problems with: Axis I condition/mental health problem. Presenting Problem Inattentiveness hyperactivity and impulsivity MENTAL STATUS EXAMINATION & BEHAVIORAL OBSERVATIONS Appearance: Well-nourished, well-groomed, and developed and in no acute distress.

Behavior: Well-controlled with good eye contact. Psychomotor activity: Normal. Speech: The client spoke at a normal rate, rhythm, and tone. Volume: Normal.

Language: Unimpaired. Mood: Anxious, worried and slightly irritable.

Affect: Full ranging, mood congruent and appropriate. Thought Processes: Coherent, i.e., logical and goal directed.

Associations: There were no flight of ideas or ideas of reference.

Attention: Markedly impaired with impulsivity and inattentiveness increased distractibility

Thought Content: There were no hallucinations, delusions, phobias, or paranoia.

Orientation: Alert and oriented in all spheres, i.e., oriented to person, place, time and situation. Judgment/Insight: Adequate.

Suicidal Ideations: There were no active or passive suicidal ideations.

Homicidal Ideations: Denied.

Memory: Grossly intact without deficits.

Fund of Knowledge: Grossly average to high average.

Past Psychiatric History: [ADHD diagnosed as a child treated with Ritalin and Adderall until she became pregnant with her daughter. No history of inpatient psychiatric services or suicidal behavior].

Substance Use History: [Occasional drink of wine without any history of illicit drug use].

Family Psychiatric History: [ Sons with ADHD and other relatives with ADHD].

Past Medical History: None. Past Surgical History: [ Partial hysterectomy due to fibroids and dysfunctional uterine bleeding]. Allergies: No known drug allergies.

Medications: [ Multivitamins]. Psychosocial History: Patient was the product of a normal childbirth. Patient had no developmental delays. She was born and raised in Oxford England. She described her childhood as good but having to move around in a military family. Patient denied having any history of abuse or neglect. Patient is a high school graduate. Has a bachelor’s degree. She is currently married with 4 children 2 biological children and 2 stepchildren. She currently works in marketing however this job has been adversely affected due to her ADHD related symptoms.

History of Present Illness: This patient is self -referred reports being diagnosed with ADHDs as a child and was treated with Ritalin and Adderall until 2006, she discontinued her medications when she became pregnant with her daughter. The patient never undergone any inpatient psychiatric services and never engaged in any self-injurious or suicidal behavior. Patient continues to have difficulty completing tasks. Patient has difficulty trying to relax or to do quiet activities such as reading or watching television. Patient also has a significant history of relational issues due to becoming easily frustrated, hyperactive, impulsive, inattentive, and disruptive in social settings. Patient has a history of difficulty focusing attention on conversations, reading materials, or tasks and frequently moves from one task to another. Patient's job performance has not met standards or expected progress secondary to impaired organizational skills, difficulty with time management and difficulty concentrating on one task at a time. IMPRESSION: Current symptoms supports diagnosis of ADHD, combined type with a predominance of impulsivity, hyperactivity, and inattentiveness without any evidence of Other severe mental health disorders. The patient’s condition is amenable to the use of psychostimulants an ongoing follow-up. RECOMMENDATIONS: 1. Adderall 20 mg every morning for ADHD related symptoms

2.Refer to a psychotherapist of Development of executive/cognitive skills to manage symptoms of ADHD.

3. Random drug screens as needed to ensure compliance with education regimen.

Use emergency services as needed for evaluation and management of suicidal or homicidal urges or hallucinations, medication problems or if your condition worsens.

Prognosis: If the client participates in long-term therapy and a regimen of psychotropic medication over an extended period, his prognosis is fair to good. The combination is essential. Reduce symptoms of distress which calls psychosocial and occupational impairment.

Objective Adderall 20 mg by mouth daily for ADHD related symptoms Treatment Frequency Monthly.

Name: E.L. Age: 42 years Purpose of Note: Initial psychiatric evaluation. Chief complaint: Patient complains of being excessively worried and stressed-out on most days due to upcoming and past events. Patient additionally endorsed having racing thoughts, accompanied by irritability, low frustration tolerance, difficulty concentrating, muscle tension/headaches, difficulty relaxing which causes asleep and/or staying asleep. Patient additionally claims having onset of panic attacks from time to time. Diagnosis: F41.9 - Anxiety disorder, unspecified Risk to self/others • NONE Mood • good • Anxious Appearance • well-groomed, and develop. Speech • normal rate, rhythm, and tone. Thought Process • Goal Directed Insight/Judgement • Good Psychosis • NONE Family Hx Son with ADHD and mother with unknown mental health condition Social Hx: Drinking, smoking, rec. drugs Psychosocial History: Patient was the product of a normal childbirth. Patient had no developmental delays. Patient denied having any history of abuse or neglect. Patient is a high school graduate. Deployment history: unremarkable. Assesment/Plan/Medication MENTAL STATUS EXAMINATION: ATTITUDE: This patient is a cooperative pleasant and in no acute distress. APPEARANCE: The patient is well groomed and dressed. EYE contact: Patient [good] eye contact. SPEECH: The patient spoke with a normal rate, rhythm, inflection and tone. PSYCHOMOTOR ACTIVITY: Psychomotor activity [normal]. MOOD: Mood was dysphoric with a [constricted ] range of affect that was mood congruent and appropriate. THOUGHT PROCESS: Thought processes were logical, linear and goal directed without any flight of ideas or loosening of associations. THOUGHT CONTENT: The patient's thought content showed no active/current suicidal ideations or homicidal ideations, auditory or visual hallucinations. There were no delusions or phobias. COGNITION: Cognition was alert and oriented in 3 spheres. MEMORY: Short-term and long-term memory were intact without deficits. JUDGMENT: Adequate. INSIGHT: good. INTELLECT: Patient's intellect is grossly [average].

SOCIAL INTERACTIONS: Patient's interactions with others were [appropriate and spontaneous]. Physical Exam: Gait/Stance: Normal/Normal. Muscle Tone/Bulk: Normal/Normal Psychosocial Stressors :Psychological symptoms related to mental health condition and legal issues i.e. emergency detention order. RISK LEVEL: Low Risk: There is No clinically significant risk of harm to self or others. History of present illness: The patient also was diagnosed with diabetes type 1 10 years ago which coincide with the onset of anxiety problems. Over the last several years the patient has been using Xanax 0.5 mg 3 times a day prescribed by his primary care manager. The patient self-referred to undergo psychiatric care in order to continue management of his anxiety using Xanax with the consideration of using other psychotropic medications as well. Patient additionally claims having onset of panic attacks from time to time which are relieved with the use of Xanax taken as needed which caused the patient to run out of his Xanax supply sometimes 4 or 5 days prior to the end of the month. Patient denies having any ongoing depressed, irritable moods and denies having any other symptoms of depression except for the onset of crying spells without any ongoing moodiness or mood swings or symptoms of bipolar disorder. Patient denied having any current suicidal ideations, suicidal or self injurious behavior, homicidal ideations, history of violence, ritualistic or bizarre behaviors. Patient also denies using any illicit drugs except for occasional use of marijuana use 2 help manage his chronic pain problems due to his polytrauma injuries sustained in a motor vehicle accident 5 years ago.

RECOMMENDATIONS/PLANS: 1.Discharge to Home: 2.RX: xanax 0.5 mg po tid. The risks benefits and alternatives to using this medication were discussed with the patient (and/or person(s) legally responsible for the patient) 3.Referral: Outpatient Mental Health Services, e.g. local MHMR for further evaluation and treatment using psychotherapy to manage symptoms of distress. 4.Go to the emergency room if condition worsens such as the development of suicidal/homicidal plans, intentions or hallucinations.

Name: LW

Age: 13

Gender: Female

Purpose: Medication Management

Chief compliant: Extreme irritability, intense temper outburst, LW stated she is ugly, people don’t like me, aggression towards sibling in the house, the academy is poor, not able to maintain a healthy relationship with peers.

Diagnosis: Disruptive mood dysregulation disorder Generalized Anxiety disorder.

Allergy: Seasonal allergy Family psychiatric history: Bipolar disorder in mother when young.

Medical history: Anemia, Sinusitis.

Mood: Irritable Appearance: WNL Speech: clear, coherent

Psychosis: None

Thought Process: Goal-Directed

Insight/Judgement: Good

Psychosis: None

Her mother was concern about LW, and how they can help her less disruptive.

Medication Prescribed 1. Quetiapine Fumarate 200mg Tablet

2. Duloxetine 30mg Delayed-Release Capsule

Plan

1. Recommend counselling, support and therapy.

2. Encourage adherence to treatment plans, as tolerated.

3. Continue current medication regimen, as tolerated. The risks, benefits, and alternatives to treatment were discussed with the patient who acknowledged this information.

4. Use emergency services, as needed, if suicidal or homicidal thoughts or hallucinations occur.

5. Follow up in 4 weeks.