Main Post 1:
Transcript for Psychiatric Interview and Mental Status Exam
Interview and Mental Status Exam: Georgianna Shea,
Case Study #2
Georgina:Hi, Cory. Case two. My name is Georgina Shay. I'm a DNP nursing student
at UMass. How are you doing today?
Cory:Okay.
Georgina:I'm going to go over a few things first. I already spoke with your mom. We've
gone over a few things and I've given her some paperwork that talks about
confidentiality. I want you to look over these as well. While we're here, it gives me
permission to talk to you and provide treatment options if needed. Whatever we talk
about today will remain confidential unless I feel like you say something that would hurt
yourself or hurt others. Then we'll have to go into it a little further. Okay, so I talked to
your mom already and she says that you're not doing too well in school.
Cory:Yeah. That's true.
Georgina:What's happening in school?
Cory:Well I mean my grades have just been getting worse. I don't really know. They're
just getting worse every semester, so I don't know.
Georgina:She says your grades are falling. Do you think so?
Cory:Yeah. According to the report card, they're definitely getting worse every
semester. I haven't failed anything yet, I don't think.
Georgina:What grade of school are you in?
Cory:I'm a sophomore. I barely made it to sophomore year, though. I almost did fail
some classes last year, but I'm a sophomore in high school.
Georgina:What was happening in your classes last year?
Cory:I just wasn't doing the homework or forgetting to do the homework, not studying,
studying sometimes. Then just in my main class, just ... I don't know. Not paying
attention.
Georgina:Do you feel like your classes are too easy for you?
Cory:No. Now it's just I just can't concentrate, I guess. I don't know.
Georgina:Are they too hard?
Cory:No. I can do the quizzes and stuff. It's not like I need extra help or anything. I
don't know. Sometimes I miss some stuff because I don't look at the board or I don't
take the right paper home, so I can't do the homework. Yeah. It's more than just me, I
think. I don't think it's they're too easy or too hard. It's just for me, it's not working.
Georgina:Are there any classes that you really like?
Cory:Well, yeah. I like a couple classes, but mom says they're not really real classes
for high school. They're like woodshop, gym. She's more worried about history, math.
You know, the normal classes.
Georgina:Why do you think you like woodshop and gym so much?
Cory:I mean gym because I love sports. You're not always doing sports, but you're not
just sitting there all day for the whole class. You can move around and do stuff.
Woodshop, I like to work with my hands and build things, learn new things. I'm always
[inaudible 00:03:15] class and that's why my GPA looks okay-ish sometimes, because I
do good in those classes. Like I said, those aren't the main classes. Those don't really
count.
Georgina:Do you feel like you're struggling in school?
Cory:Yeah. In comparison to other people, I guess, in my class. Yeah. I mean my
teachers say ... They don't say stupid, but they say I make careless mistakes. I don't
pay attention. I don't take notes. They tell me, "Stop doodling. Stop talking." I want to do
better, I guess. It's just I don't know how, I guess. I don't know.
Georgina:Do you have a lot of friends in school?
Cory:Yeah. I get along with a lot of people mostly out of my class. I have like two or
three friends or something. I always have someone to talk to or something. Yeah.
Georgina:Do you ever play any sports or extracurricular activities?
Cory:I wish. I'm not allowed to since starting high school because my grades have just
been going down. I used to play basketball, baseball all the time. I played like I said 'til
high school and then mom said I'm not eligible to play until I have a better GPA. I
couldn't try out. It pisses me off. I want to play. The coaches said they wanted me to
play. It's just mom won't sign the papers, so I can't play. I can't play.
Georgina:Did you have any struggles in school before this year?
Cory:Yeah. I've always not done the best. I never had straight As or straight As and Bs
or anything like that, but I just get by and stuff. I never stay back or need to go to a
special classroom or anything like that. It's just more like my grades are whatever. Bs,
Cs. Every now and then I get a D, but they've just been getting worse every year.
Georgina:Are there any other classes that you're really interested in besides
woodshop and gym?
Cory:I guess not really. I don't know. I know [inaudible 00:05:39] grow up to be a
carpenter or a gym teacher, so I probably should pick something, but I don't know.
Math. I've always had trouble with math, so I don't really like math. Reading and writing,
I always get mistakes all the time. Every time I write a paper, it's like careless mistakes.
It's all red. Redo it. I always lose that. I'm just frustrated with that. I [inaudible 00:06:03]
everything. That's what I thought. History. I've never liked history. Science. I guess
science, if I had to pick something. Science is always cool. I like to experiment, like how
you can do the labs and stuff, but the formulas and stuff are just too ... Too detailed? I
don't know. Mom says I'm not good at details, so I forget things or even the
experiments. I want to do experiments, but I [inaudible 00:06:31] everything. I want to
make this reaction. I just pour the stuff together and sometimes I get in trouble. I like
science, but I'm not ... It's just like every other class. I'm not good at it.
Georgina:Do you think you have trouble concentrating in school?
Cory:Oh, yeah. I can't concentrate. If I have gym first period, that's good, or gym and
woodshop first. Then I can get some energy out and do stuff, but if I have them at the
end of the day, I can't do anything at the end of the day. I'm just sitting there, doodling. I
doodle all the time. I just draw little pictures or talk to my friends, text on my phone. I
don't know. I can't just sit there and take notes every class for 50 minutes and not be
able to talk or anything. I read, go do ... Walk to the bathroom, walk around the halls,
meet my friends in the halls, talk to them, but I can't do that all day. I don't know.
I might have a class or two I can do good in and concentrate. Sometimes I have trouble
slowing down or commenting. I talk too fast sometimes and I get really excited and I talk
or there's times where I just don't talk at all because there's nothing interesting.
Georgina:Do you feel like you daydream in school?
Cory:I don't really daydream. I think about the stuff I would rather be doing. If that's
daydreaming, I don't know. I think about playing sports or if there was a sports game,
like baseball or something for the school, I think about what happened. I won't be
playing it. Listen to announcements happening. Yeah. I mean I'm not really looking at
the board, so I guess yeah, I'm daydreaming.
Georgina:How about your classwork while you're in school? Do you struggle with that?
Cory:I mean that's probably where I get most of my good grade from just because it's
right there. I can ask the teacher if I need something. Sometimes we have quizzes and
stuff still on the board, so I have to take notes and remember it so I can just do it. Tasks
and stuff, I don't really do that good because I don't study or remember to study. I don't
know. Coursework is okay.
Georgina:Your mom says you don't listen to the teachers. Do you feel like you're not
listening to the teachers?
Cory:Well I don't know what they tell her what happens, but as far as ... They want me
to pay attention, take notes and be this [inaudible 00:09:10] sits in the front seat and
does everything, but I'm doodling. They tell me to stop doodling and I don't stop
doodling because I don't know what I'm supposed to do or I get out of class and go to
the bathroom every day. They don't like that. I don't know if I'm not listened to. It's just
like I need to do something. I guess I need to do something. I can't just sit there and
watch a slideshow and take notes. I guess if they say that's not listening, then yeah, I
guess. I'm just trying to figure out what to do to stay in the room. I don't know.
Georgina:You don't find that classes are too hard or too easy. You just have no
interest.
Cory:I guess.
Georgina:Is that what you're saying?
Cory:Yeah. No interest or just not sustained interest, I guess. If it's a half day, I do
good on half days. Half days at school, I do okay because all the classes are shorter.
[inaudible 00:10:12] half day. I could do really good.
Georgina:Okay. What about at home? Do you get your homework done at home or do
you find that you struggle with homework also?
Cory:Did you ask my mom that?
Georgina:I did ask your mom that. I want to know what you think about that.
Cory:I'm pretty sure she probably told you the same thing I'm going to say is that she
tries to get me to do homework. I can't do anything 'til I do my homework, but I don't do
homework because by the time I get home, I'm already drained from being at school all
day, trying to concentrate and being frustrated. Probably didn't take any notes or I forgot
the book. It's always something I forget. Either I forget the book, I forget the actual sheet
I'm supposed to do, I didn't take the notes in class. It's never complete even when I do
it. It's like what's the point? Most of the time I don't do my homework, which I'm sure
doesn't help my grade, but I just can't remember to do everything, I guess. Shit I need to
do to get it.
Georgina:Do you get really distracted when you're trying to do your homework?
Cory:I guess. Yeah, because I'm home. My video games are there. My cellphone is
there. Food's there. TV is there. All these other options outside school where I have
nothing. Just sit there, leave the classroom. Do I want to try to do homework that I don't
even know or do I want to do something else? Now I try to do both, play video games
and read. That type of thing. Or try to eat dinner and then go do my homework at the
end of the night, but I'm too tired. I have trouble with time management, too. That's what
mom says. She [inaudible 00:11:58] I wait 'til I'm tired so I'm not going to do it because
I'm frustrated. I don't really know.
Georgina:Okay.
Cory:I don't know.
Georgina:Do you have any job outside of school?
Cory:No.
Georgina:No?
Cory:No. I have to get one in the summer, though, but I just turned 16 so I couldn't get
one before or anything. Sometimes me and my friends go and shovel people's
driveways and stuff in the neighborhood or rake people's leaves and stuff. It's not a real
job, but no, I don't have a job. Like I said, I can't play sports, which is what I want to do. I
don't really do much at home besides during the weekend because I'm not allowed to
go to friends' houses or anything. I just chill out at home.
Georgina:How about your room at home? Do you like to keep it nice and clean or ...
Cory:No.
Georgina:No?
Cory:I think it's organized, but I know where everything is. It's not clean like the rest of
the house, but mom asks me to ... Or anyone asks me, "Can you go find this?" I'm like,
"Yeah, that's fine." I have piles of stuff. Just if someone else walked into my room, they
couldn't find it, but it's not the worst. I have friends that have [inaudible 00:13:08] mine is
semi-organized, at least in my head. I don't know.
Georgina:Do you feel like you lose things a lot or do you think you're pretty organized?
Cory:Well sometimes I lose stuff. I've lost a couple binders already this year. I have no
idea where they are. I lost the house key twice this year. I just have no idea where it is.
It's probably in my room, mom says. To go clean my room, go find it and it not be there.
I just make more copies. Yeah, I forget stuff. Sometimes I forgot my lunch at home. That
happens probably once a week. Don't know how that happens, but I forget. Like I said,
with the homework, I just forget one of the three things. Notes, book or the actual
homework. I forget my passwords sometimes. I don't know.
Georgina:You seem to talk about your mom an awful lot. Can you tell me a little bit
about your relationship with her?
Cory:Yeah, just because mom is always on me about everything. She's the reason I'm
here. Everything comes back to her wanting me to do better. I mean she's my mom, so
she wants me to do better, which I understand. She gets upset with me and frustrated
with me and whatever. I didn't decide to do this on purpose. Sometimes she makes me
feel like I'm choosing to do bad or not going to listen or I'm not doing homework. I'm not
choosing to do that. It just doesn't work sometimes for me, so I get frustrated with her
and she gets frustrated with me. We used to be closer when I was able to play sports.
I'm upset that I can't play sports now, so obviously that makes it so we disagree more
often because I want to play sports. She won't let me play sports. She said if I come
here and figure stuff out, then maybe I could play sports. That's why I'm here. I want to
play sports again, you know?
Georgina:Do you feel like you disappoint your mother?
Cory:Yeah. She tells me all the time I disappoint her. All the coaches at the high school
said they want me to play. My dad's mad that I can't play because mom is saying that I
have to do better in school. She said she's disappointed so I can't play. Yeah, I already
know I disappoint her, but now I'm disappointed [inaudible 00:15:29] can't play sports.
That's what everyone thinks I should be doing and what I want to do.
Georgina:How does that make you feel, knowing that you're disappointing her?
Cory:I guess I'm sad that I'm disappointing her, but I'm more sad that I can't play sports
[inaudible 00:15:46] these are kids that I've played sports with my whole life. We were
on the same teams during traveling teams. We did everything together and now the
past few years or year and a half or whatever it is, I haven't been able to play. I'm
probably not going to play next year. I'm not going to just be able to join JV or varsity my
junior year. It's hard to deal with not being able to play sports.
Georgina:You talked about your mom and your dad. Do you live with both parents?
Cory:Yeah.
Georgina:Do you have any siblings?
Cory:Well I have one sister, but she doesn't live with us all the time because she's in
college. She's only there during winter break or summer break or something. Mostly just
me and my mom. We don't have any pets or anything. It's mainly just us. My parents
and me.
Georgina:What do you like to do for fun at home?
Cory:Well I can't do anything really during the week because I don't have good grades,
so I just play video games or I guess call my friends to hang out and go online, go on
my phone to play games, go outside and play. On weekends, I hang out with my friends
still. We play sports outside. We play basketball, but that's really it. We hang out with
[inaudible 00:17:04] sometimes, but not very much.
Georgina:Sounds like you really like outdoor things.
Cory:Mm-hmm (affirmative). Yeah.
Georgina:Things that get you moving.
Cory:Yeah. Like I said, I always have [inaudible 00:17:15] sports. I try to be active, try
to do stuff outside, but mowing the lawn or just doing anything outside. I don't like just
sitting still. I don't like going to the movies or stuff like that. Mom asks me if I want to go
to the movies. I'm like, "I don't want to sit there for that long and do nothing." Or I play
video games. Just anything. Hiking, swimming, summer. I love summer because no
school and you can just do whatever you want. Mom says summer only comes if you do
good in school. If not, you're going to school. It's like what am I supposed to do? I don't
know what I'm supposed to do.
Georgina:How long do you usually play video games for when you play?
Cory:Well I'm not supposed to play that much, but if me and my friends are online
together or something, playing ... I don't know. Sports games or Call of Duty or
something. We're all playing stuff. I'll play for a couple hours. Weekends, probably two
to three hours at night just because there's nothing else to do. We'll play online all night
or something. All when my friends are on and stuff.
Georgina:Do you feel like you can sit and concentrate on that for a while?
Cory:I mean that's fun. Yeah. I mean that's different I think just for playing. I have the
gaming chairs, the controllers, the headset. You're not just sitting there, not moving or
anything. I'm using my hands and talking. I'm able to just do whatever I want to do. I
don't know. That's different I guess for me than just sitting in school, but I don't know.
Maybe it's not.
Georgina:How do you feel like you're sleeping at night?
Cory:I don't know. I guess it's okay.
Georgina:Do you feel like you're rested in the morning when you go to sleep?
Cory:Yeah, I guess. Sometimes I'm tired if I'm up late, playing video games or
something, or if I had trouble falling asleep. Sometimes it takes me a little bit to fall
asleep. [inaudible 00:19:23] or something. I sleep okay, I guess.
Georgina:Do you feel like you have a lot of thoughts in your head at night and you just
can't get them to help you fall asleep?
Cory:I mean sometimes.
Georgina:Are you thinking about a lot of things and just can't rest your head?
Cory:I think as far as my body is not tired ... My body is tired. It's just my body does ... I
don't know. Especially when I can't play sports or anything and I'm just at home all day
or something. I have so much energy. It takes me awhile to calm it down. I try different
things, but sometimes just ... I don't know.
Georgina:Do you feel like if you have a good night sleep, say from eight to eight, your
concentration would be better at school?
Cory:No, I don't think so. I don't think it has anything to do with that. I'm yawning right
now. I don't think it has anything to do with the amount of sleep I get. I think it's just
school is different.
Georgina:Okay. Do you ever drink any coffee, caffeinated beverages, energy drinks?
Cory:No. I mean I don't drink coffee. I don't like coffee. Never have. Sometimes if I'm
up, like I said, playing video games or something, I'll drink a Monster or a Red Bull or
something, but that's not regular because I don't know. Caffeine is not good for you
when you're a kid and stuff. It makes me even more hyper. I don't drink that. No, I
guess. I drink soda, though.
Georgina:Okay. I'm just going to ask you a few other questions now.
Cory:Yeah.
Georgina:These questions that we ask every month. We're going to start with a couple
things. Do you have any allergies that you know of?
Cory:Bees. That's it.
Georgina:Bees. Have you ever had to be hospitalized for anything?
Cory:No. I've never stayed overnight in a hospital. Just bumps and bruises, sprained
ankles and stuff, but that's it.
Georgina:Okay. I'm going to ask you three words and then I'm going to have you
repeat them back to me a little bit, okay?
Cory:Yeah.
Georgina:The words are green, ball, cat.
Cory:Okay. Green, ball, cat.
Georgina:Green, ball, cat. Okay. Could you spell the word "world" backwards for me?
Cory:D-L-R-O-W.
Georgina:Okay. Do you know what day it is today?
Cory:Saturday.
Georgina:Saturday. What year is it?
Cory:2016.
Georgina:Okay. Have you ever had counseling before?
Cory:No. I've never been to anything like this before. I've been to the doctors, but no,
never counseling.
Georgina:Okay. Have you ever felt sad?
Cory:Yeah. I mean I've felt sad before.
Georgina:Low?
Cory:Well I feel sad now that I can't play sports and stuff, but I've never felt like some
people get depressed or something. I never felt like that.
Georgina:Have you ever had thoughts of hurting yourself?
Cory:No.
Georgina:Or hurting anybody else?
Cory:No. I would never hurt myself or anyone else.
Georgina:Do you ever feel that you're impulsive?
Cory:Sometimes I can be impulsive, just if I want to go get to the mall or something or I
want to go play sports. Me and my friends will make plans at the last minute, but no,
nothing crazy.
Georgina:Okay. Have you ever heard voices in your head that other people can't
hear?
Cory:No, I've never heard anything like that.
Georgina:Okay. Can you tell me those three words again?
Cory:Green, ball, cat.
Georgina:Green, ball, cat.
Cory:Yeah.
Georgina:Okay. It seems like you're having some trouble in school. You're not able to
pay attention in class. You're very good at sports.
Cory:Yeah.
Georgina:You really like sports. You really want to play sports again.
Cory:Absolutely.
Georgina:It sounds like you feel like you're disappointing your mom because she
doesn't understand that you're trying, but you just can't seem to concentrate. Does that
sound right?
Cory:Yeah. That's just how I feel.
Georgina:Okay.
Cory:I don't know what to do, though.
Georgina:I think what we'll do is we'll continue meeting, okay? I think what it sounds
like is you're having some symptoms of attention deficit hyperactivity disorder.
Cory:Okay.
Georgina:Okay. What I'll have you do is come back and visit me again in two weeks.
Cory:Okay.
Georgina:In the meantime, I'll have you see somebody for some extra testing.
Cory:Okay.
Georgina:Then once we get those results, come back and we'll talk. We'll see what
other treatments are needed.
Cory:Okay.
Georgina:Get you back on that varsity team.
Cory:Okay.
Georgina:How does that sound?
Cory:I'm good with whatever will get me back on the sports team. I will do whatever,
but I just hope it's good enough for mom because I just ... I want to play sports. I guess I
can play basketball this year if I can get them up, but I don't know how long it's going to
take. Whatever. I just want to play sports.
Georgina:Okay.
Cory:Okay. All right.
Georgina:Do you have anything else you want to talk about?
Cory:No. We'll just meet again and then we'll do the testing?
Georgina:Yeah.
Cory:Okay. Are we all set now?
Georgina:Yeah.
Cory:Okay.
Georgina:Do you have any other questions?
Cory:No. I'll just talk to mom about it and stuff. I'm sure the testing will be fine.
Georgina:I will bring her in next and we'll talk with you. We can all talk about it
together.
Cory:Okay. Let's do that then. That's fine.
Georgina:All right.
Cory:Thanks.
Georgina:Sounds good.
Cory:All right. Cool.
Psychiatric SOAP Note
Tasha:
Subjective: The patient, a 32-year-old male, presents with complaints of depression and
anxiety. He reports feeling sad most of the time for the past month and has been having
trouble sleeping and eating. He also reports feeling irritable and easily frustrated. The patient
denies any suicidal or homicidal thoughts.
Objective: On examination, the patient appeared sad and had a flat affect. He reported feeling
hopeless and helpless. The patient's speech was slow and his thought processes were
tangential. The patient's mood was depressed and his affect was restricted.
Assessment: The patient appears to be suffering from major depressive disorder with possible
features of anxiety. Further evaluation and treatment are warranted.
Plan: The patient will be referred to a psychiatrist for further evaluation and treatment. The
patient will also be instructed to follow up with his primary care provider for any additional
medical concerns. A medication regimen may be initiated to manage the patient's symptoms.
Psychotherapy may also be considered as part of the treatment plan. The patient will be
scheduled for a follow-up appointment in 2 weeks.
Subjective: At the follow-up appointment, the patient reports feeling better overall but still
experiencing some symptoms of depression and anxiety. He has been taking his medications as
prescribed and has been attending weekly therapy sessions.
Objective: On examination, the patient appeared more alert and engaged. His speech was
normal and his thought processes were coherent. The patient's mood was improved and his
affect was more appropriate.
Assessment: The patient's symptoms of depression and anxiety have improved but are not
completely resolved. The medication and therapy interventions seem to be helping.
Plan: The patient will continue with his current medication regimen and therapy sessions. The
patient will be instructed to follow up in 4 weeks for a medication check and to assess
treatment progress. The patient will also be educated on the importance of medication
adherence and the potential side effects of his medication. The patient will be encouraged to
continue practicing healthy coping skills and self-care habits to manage his symptoms.
Subjective: At the 4-week follow-up appointment, the patient reports feeling much better and his
symptoms have significantly improved. He is sleeping and eating better, has more energy, and is feeling
more positive about his future. He reports having better control over his anxiety and is able to manage
his stressors better.
Objective: On examination, the patient appeared more relaxed and positive. His speech was normal and
his thought processes were organized. The patient's mood was euthymic and his affect was congruent.
Assessment: The patient's symptoms of depression and anxiety have significantly improved with
medication and therapy. The treatment plan is effective and the patient has made significant progress.
Plan: The patient will continue with his current medication regimen and therapy sessions. The patient
will be instructed to follow up in 3 months for a medication check and to assess treatment progress. The
patient will be encouraged to continue practicing healthy coping skills and self-care habits to maintain
his progress. The patient will also be educated on the importance of continuing his medication as
prescribed and the potential risks of stopping or altering his medication without medical supervision.
Criteria Clinical Notes
Subjective Pt is Caucasian male who presents alone due to “my grades are getting worse every
semester.” Pt is an adequate historian. He reports struggling with not being able to pay
attention, poor concentration, poor focus, forgetfulness, talks too much in class, and
hyperactivity for several years. He states his teachers say he does not listen in class,
doodles too much, and makes careless mistakes on schoolwork. Pt denies depressive and
anxious symptoms. He has no history of psychiatric treatment. Pt lives with his parents and
reports a good relationship with both. Pt reports feeling as though he “disappoints his
parents due to his declining grades.” Denies family history of mental illness. Denies alcohol
and drug use but sporadically drinks “Monster or Red Bull.” Pt reports his general physical
health is good. He is not taking any prescribed medications. His sleep is good but endorses
some trouble falling asleep. He denies racing thoughts and impulsiveness. He is in the
10thgrade and has two or three friends at school. He has played basketball and baseball all
his life but is not playing currently due to his poor grades. He endorses some sadness about
not playing sports.
Include chief complaint,
subjective information from the
patient, names and relations of
others present in the interview,
and basic demographic
information of the patient. HPI,
Past Medical and Psychiatric
History, Social History.
Objective Pt is alert and oriented to person, place, time, and event. He has short, brown hair,
appropriately dressed, well-nourished with adequate hygiene. Eye contact is good and he
relates to the examiner in a socially appropriate way. Mood appears euthymic. Affect is
anxious. He is fidgeting and moving in his seat throughout the assessment. Speech is
normal. Thoughts are goal-directed and linear, without delusions or hallucinations. Remote,
recent, and recall memory are good. He recalled 3 objects of green, ball, cat and spelled
world backward adequately. Insight, judgement, and impulse control appear adequate.
Denies SI/HI.
This is where the “facts” are
located. Include relevant labs,
test results, vitals, and Review
of Systems (ROS) – if ROS is
negative, “ROS
noncontributory,” or “ROS
negative with the exception
of…” Include MSE, risk
assessment here, and
psychiatric screening measure
results.
Assessment
Diagnosis:
Attention Deficit Hyperactivity Disorder, combined type F90.2
R/O Substance Use Disorder
R/O Mood Disorder
R/O Anxiety Disorder
R/O Hyperthyroidism
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.
Plan
1. Refer for Psychological ADHD testing
2. Obtain BP, CBC, CMP, TSH, Drug screen
3. Obtain ROI for teachers. Have teachers and parents complete the Conner’s Scale.
4. Individual Psychotherapy for CBT, mindfulness, and learn self-management strategies.
5. Collaborate with Pts Family for support and ongoing education.
6. Follow up in 2 weeks
Prognosis: Good due to supportive family and appears motivated for change.
IDENTIFICATION
The patient is an adolescent boy on high school student that comes to the office for initial
psychiatric evaluation. He is a reliable historian.
CHIEF COMPLAINT. “My grades have just been getting worse. They're just getting worse
every semester”
HISTORY OF PRESENT ILLNESS.
An adolescent boy comes to the office because of problems with school performance. He is in
high school, and his mother is concerned due to her son is not doing too well in school. Pte has
reported that he wasn't doing the homework or forgetting to do the homework, not studying,
studying sometimes, just in his main class, Not paying attention. He has not been turning in his
assignments and he is falling behind in History, Math, Reading, and Writing, reporting he has
never liked them. However, pte states “Science is always cool.” Because he likes to experiment,
and how he can do the labs and stuff, but the formulas and stuff are just too detailed for him.
Nevertheless, he likes the gym because he loves sports, because he can move around and do
stuff. And, he does not like to be sitting for the whole class all day. Also, pte verbalizes likes
Woodshop, he likes to work with his hands and build things, learn new things. He says that
always Woodshop class his GPA looks okay sometimes because he does good in those classes.
In the office, he is sitting calmly but constantly,he makes repeated movements with his hands
and head and touches his face.
Denies any symptoms of depression, manic, or psychotic. No auditory or visual hallucinations.
No delusions, no suicidal or homicidal ideation.
Psychotherapy session included a discussion of diagnosis and treatment, the risks and purpose of
medications, medication compliance, relapse prevention, identification of support people in the
patient's life, addressed patient's fears, concerns, desires. The patient has expressed that he still
maintains an active social life and reports that his mood is fine
OBJECTIVE
GENERAL APPEARANCE BEHAVIOR AND ATTITUDE:
An adolescent who is casually and neatly dressed and in no acute distress. The patient engaged
the examiner in a cooperative, friendly, and polite manner.
Has unusual mannerisms and gestures. No psychomotor agitation or retardation. Posture and gait
are normal. Eye contact is good.
SPEECH: Reaction time to questions was normal. Normal rate. Spontaneous. Normal Volume.
MOOD: "Good"
AFFECT: Full. Congruent with mood. Appropriate to situation.
FLOW OF THOUGHT: The patient's stream of mental activity was logical, relevant, coherent,
and goal directed with no evidence of flight of ideas, looseness of associations, thought blocking,
racing thoughts, circumstantiality, or tangentiality.
THOUGHT CONTENT: The patient's thought content revealed no evidence of delusional
ideation, interference or responses to internal stimuli, obsessions, or any specific preoccupations.
No suicidal or homicidal preoccupations. The patient was alert and oriented in all three spheres.
COGNITION: Has problems with working memory (short-term memory) impairment due to
failure to pay close attention to details or making careless mistakes in schoolwork. He avoids,
dislikes, and is reluctant to engage in tasks that require sustained mental effort (such as
schoolwork or homework). Attention and concentration were fair. The fund of general
information was fair. Comprehension and understanding were fair. Therefore, intelligence was
estimated to average; and consistent with the level of formal education. Judgment, insight, and
reliability appeared to be fair.
ASSESMENT
DSM-5 Attention-Deficit/Hyperactivity Disorder: According to the American Psychiatric
Association, ADHD is a problem of inattention, hyperactivity, and impulsivity. (2013).,ADHD is
a chronic condition with symptoms that begin in early childhood but often persist into adult life.
A key element of the definition is functional impairment across 2 or more domains, most often in
school and at home.,,As a result, ADHD can limit academic, interpersonal, and occupational
success and can also lead to greater risk-taking and accidents.,,American Psychiatric
Association. (2013).
Combined (hyperactive and inattentive types) due to pte exhibits:
Often fidgets with hands and feet in seat
Often leaves seat in classroom in which remaining seated is expected
Often has difficulty engaging in leisure activities quietly
Often fails to give close attention to details and makes careless mistakes in schoolwork
Often has difficulty sustaining attention in tasks activities
Often has difficulty organizing tasks and activities
Often avoids, dislikes, and is reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or homework)
Is often forgetful in daily activities. (WHO.2014)
TEST
ADHD is considered a behavioral disorder and is diagnosed by clinical history;
neuropsychological testing is neither necessary nor sufficient for the diagnosis. (Pliszka S,
2017).
SUICIDE RISK ASSESSMENT:
The patient is currently at a low risk for suicide and has no suicidal ideation, intent, or plan.
PLAN
-Improve diet
-Get regular daily exercises
-Daily relaxion and manage stress levels
- Psychoeducation
- Behavioral therapy (Lawrence W. Brown, 2019)
MEDICATIONS:
Methylphenidate 2.5 mg PO bid. Take 1 tablet 2.5 mg orally two times per day.
Start: 2.5 mg PO bid, may incr. by 10 mg/day q7 days; Take 30-45min before meals, last dose
before 6 pm. (Lawrence W. Brown, 2019)
Follow-up in two weeks.
References
American Psychiatric Association. (2013.). Diagnostic and statistical manual of mental disorders,
5th ed., (DSM-5). Washington, DC: American Psychiatric Publishing.
Pliszka S, (2017) AACAP Work Group on Quality Issues. Practice
parameter for the assessment and treatment of children and adolescents with
attention-deficit/hyperactivity disorder. J Am Acad Child Adolescent PsychiatryJul;46(7):894-
921. [Abstract]
World Health Organization. (2014) International classification of diseases: 10th revision, second
edition. Geneva, Switzerland: World Health Organization.
Lawrence W. Brown, M. (2019). Epocrates. Retrive from Epocrates, Inc. :
https://online.epocrates.com/diseases/14242/Attention-deficit-hyperactivity-disorder-in-
children/Treatment-Options
