Psychiatric evaluation

Psychiatric Evaluation

Patient Initial: J.W

Age: 31

Gender: Male

Date of service: 6/22/24

Identifying information:

The patient is a 31 year old Caucasian male who presents for a psychiatric evaluation. Patient was the primary source of information. We received documents from his former psychiatrist. Patient understands his medical history and the reason for this consultation.

SUBJECTIVE DATA

Chief Complaint: “I’m trying to get back on my meds”

HISTORY OF PRESENT ILLNESS: (SUBJECTIVE).

J.W is a 31-year-old Caucasian male who presents to the office for “ medication management.” Patient reports history of ADHD that was diagnosed when he was in high school. He reports the

psychiatrist he has had for years retired and the new one does not want to continue his medications he has been on for years. He reports the following medications has been helpful:

Adderall XR 30 mg QAM, Adderall 15 mg Q1PM, Lexapro 20 mg QAM. He reports the above medications has been working well and he would like to continue the medication. The new psychiatrist attempted to put him on trazadone but he did not want that. He reports having difficulty focusing since when he was in middle school and has been on Adderall since he was a teenager. He reports feeling down since he became a father as his friends are no longer coming to visit. He was diagnosed with depression in the past and reports being on Lexapro for the past 10 years. At the time of diagnosis, he was having financial issues and was so depressed and was drinking and got a DUI. He was also concerned about his parents divorcing at that time. He reports anxiety at that time as well. He remembers constantly pacing around and worrying about everything. He was worried about his finances and his parental issues. His mood has been well controlled with Lexapro and he has a three month refill. His Adderall was last filled in March, 2024 and this was verified via PDMP. He reports being a “stay at home” dad and is finding it difficult taking care of his two year old daughter. He exhibits symptoms of inattention. He reports difficulty sustaining attention during activities with his daughter. He often loses items like his wallet or car keys. He has difficulty finishing tasks with periods of “zoning out”. He finds his mind wanders easily and he is easily distracted. He is often forgetful and fails to pay attention to close details which results in careless mistakes. He does not seem to listen when spoken to directly and often needs directions repeated. He reports being disorganized. He reports difficulty keeping his closets, drawers, and his home clean. Tasks requiring sustained mental effort or concentration are difficult for him to accomplish. Patient reports difficulty focusing on his child and keeping up with daily tasks. He also reports difficulty waking up during the night when the baby is up.

Patient exhibits signs of hyperactivity. He is restless and often fidgety. He reports being “always on the go” and is unable to sit still for an extended period of time. He frequently participates in high risk behaviors such as driving too fast. He gets bored easily and frequently need to change activity. He reports an inner restlessness. He reports being impulsive. He is always interrupting people and talks excessively. He often blurts out answers even before questions are asked. He has a hard time waiting for his own turn. He reports drinking excessively couple years ago but no longer drinks alcohol. He is solely focused on “being a good dad” and a “good husband”.

Problem Pertinent Review of Symptoms/Associated Signs and Symptoms: Feelings of excessive or unusual anxiety are denied. Symptoms of bingeing, purging and other indications of an eating disorder are convincingly denied. He reports history of depression after his DUI and during his parent’s divorce. He had some anxiety at that time but does not currently reports anxiety. He specifically denies manic symptoms. No obsessive, intrusive and persistent thoughts or compulsive, ritualistic acts are reported. No hallucinations, delusions, or other symptoms of psychotic process are reported by him. He denies suicidal ideas or intentions. He denies ever having been sexually, physically, or emotionally abused, He denies any problems associated with anger. He denies any symptoms of grief or any chemical dependency problems.

Other Systems Reviews: There is no recent history of weight loss, fever, malaise, or other abnormal constitutional symptoms. There is no history of disorder of muscle strength or tone, joint problems, or disturbances of gait or station. Symptom reviews of all other systems are negative.

PAST PSYCHIATRIC HISTORY:

Patient was treated for ADHD/anxiety/depression from 2010-06-01 to 2024-03-11 by a psychiatrist who is now retired. He saw another psychiatrist but was unhappy with him.

PREVIOUS PSYCHIATRIC HOSPITALIZATION: He has never been psychiatrically hospitalized.

PREVIOUS PSYCHIATRIC MEDICATIONS: J. W is currently taking Lexapro (escitalopram). Current dosage is 20 mg. He states it is effective with no side effects. He was previously on Adderall (amphetamine) 30mg ER and Adderall (amphetamine) immediate release 15mg at 1PM. He reported dosage was effective with no side effects.

CURRENT MEDICATIONS: Lexapro 20mg QAM

SUBSTANCE USE/ ADDICTIVE BEHAVIORS: He has a history of possible alcohol over use. This substance was used for years. When using, he used to drink until he black out. This substance was taken by mouth. He used a few times a week. He reports last using about 5 years ago. He denied history of seizures, DTs, or withdrawal. He got arrested for a D.U.I at one point. He denies smoking, vaping, or illicit drug use. He typically avoids caffeine because it makes his symptoms worse. He eats two-three meals a day and does not exercise. His appetite is fair. He denies gambling or spending money excessively. He identifies himself as straight/heterosexual orientation. He is currently sexually active with his wife. His first sexual experience occurred at age 16.

FAMILY PSYCHIATRIC HISTORY:

J.W’s family psychiatric history is negative. There is no history of psychiatric disorders, psychiatric treatment or hospitalization, suicidal behaviors or substance abuse in closely related family members.

MEDICAL HISTORY: He denies any significant medical history. He has no surgical history. He does not get regular physical check-ups or see a primary care provider (PCP). He has no medication allergies. He denies food and environment allergies.

DEVELOPMENTAL HISTORY: He was the product of a normal delivery. There were no post-partum complications. He had speech delay when he was younger. He denies any abuse during his childhood.

PSYCHOSOCIAL:

Both biological parents were present entire childhood. He has a younger sister and had grandparents, aunts, and uncles that were present during his entire childhood. He describes her current living situation as adequate. He does not have many friends. He reported his friends stopping visiting after the birth of his daughter. He denies current financial problems. He is a stay at home father and his wife is the primary provider. He graduated from high school but never went to college. He has never served in the military. He does not participate in any spiritual activities. He is not actively involved in any community or recreational activities. He does not have current hobbies.

ASSETS/STRESSORS: He reports recent stressors mainly with his ADHD and being unable to take care of his child and be a good husband. His asset is his wife who is very supportive. He also enjoys been a dad and enjoys taking his daughter out for her activities.

OBJECTIVE DATA

MENTAL STATUS EXAM: (OBJECTIVE).

Patient appears to be his stated age and is of normal weight. He appeared disheveled and his beard is overgrown. He has poor eye contact and was hyperactive during the interview. He constantly taps or makes strange noises while the provider was taking notes. He was restless but cooperative. His speech was rapid and fast paced. He was extremely talkative. Articulation and volume was coherent and spontaneous. Language skills are intact. Mood presents as normal with no signs of either depression or mood elevation. He reports an “inner restlessness” and “frustration” sometimes. Affect is expansive and there are frequent and appreciable mood changes throughout the interview. Thought process is clear, concise, and logical. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Associations are intact, thinking is logical, and thought content appears appropriate. Suicidal ideas or intentions are denied. Homicidal ideas or intentions are denied. Cognitive functioning and fund of knowledge are intact and age appropriate. He is oriented to person, place, time and situation. He demonstrated average intelligence and general knowledge. Short- and long-term memory are intact, as is ability to do abstract and arithmetic calculations. He is able to recall three words that were said previously and he remembers what he did last weekend. He is able to count backwards from 100 to 77. He has good insight into his symptoms and verbalizes willingness to seek help. Judgment appears intact.

PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)

Limited physical exam due to telepsychiatry. Patient often checks his blood pressure and heart rate at the CVS pharmacy. He reported last blood pressure as 120/80 and heart rate was 74.

DIFFERENTIAL DIAGNOSIS:

Symptoms of ADHD can overlap with other psychiatric and medical conditions such as anxiety disorder, mood disorder, substance abuse, and hyperthyroidism. Based on the patient’s history and presenting symptoms, the following differential diagnoses were considered.

-Attention-deficit hyperactivity disorder, combined type: Adult ADHD can present differently and symptoms include hyperactivity, difficulty starting task or finishing, frustration, impulsivity, chaotic life styles and disorganization (Gentile et al., 2006).

– Major Depressive disorder (MDD): Patients with MDD can present with inattention and become easily upset, however additional symptoms such as depressed mood, loss of interest or pleasure in most activities and fatigue would be present (Gentile et al., 2006). These symptoms are usually lasting at least two weeks (Gentile et al., 2006).

-Generalized Anxiety disorder (GAD): Patients with GAD may show hyperactive behaviors such as fidgety or inattention. GAD is frequently accompanied by persistent worry and fear and somatic symptoms of anxiety (Gentile et al., 2006).

– Medical conditions such as hyperthyroidism, drug interaction, sleep apnea, lead toxicity, seizure disorder, and head injury can mimic symptoms of ADHD (Gentile et al., 2006). Most of these can be ruled out with lab testing, imaging and clinical presentation.

DIAGNOSTIC IMPRESSION WITH FORMULATION:

Attention-deficit hyperactivity disorder, combined type, F90.2 (ICD-10)

Adjustment Disorder with Mixed Anxiety and Depressed Mood, 309.28, F43.23 (ICD-9)

Alcohol Use Disorder, Moderate, 303.90, F10.20 (ICD-9)

ADHD is often characterized by periods of developmentally inappropriate attention, motor restlessness, and impulsivity which can have significant impact in a person’s work and home life (Stahl, 2014). He has at least six symptoms of inattention as well as at least six symptoms of the impulsivity/hyperactivity which necessitates a diagnosed of ADHD, combined type (American Psychiatric Association [APA], 2022). Diagnosis of ADHD requires persistent symptoms for at least 6 months which have been maladaptive.

The patient was also diagnosed with an adjustment disorder with mixed anxiety and depressed mood. APA (2022) noted that while it is often difficult to differentiate a depressive episode from an adjustment disorder, adjustment disorder often emerges after a life stressor in this case after his DUI arrest. The patient did not meet criteria for major depressive disorder. He was unable to state exactly what his depressed mood was at that time or how long it lasted. It appears he concurrent periods of anxiety in between depression.

RISK ASSESSMENT:

Patient was assessed for potential risks to self and others. He denies suicidal intent or ideation. He also denies homicidal ideation. He has no history of trying to hurt herself or others. There are no indication or suspicion of substance abuse. He feels safe at home and he appears to have good judgement. We discussed seeking immediate help if he felt hopeless or helpless and have thoughts of harming herself or others.

RECOMMENDATIONS AND PLAN

The purpose of medication for treatment of ADHD is to improve attention, facilitate working memory, reduce psychomotor activity, and decrease disruptive behavior (Gentile et al., 2006). There are stimulants and nonstimulant medications but stimulant remain a first line treatment for adult ADHD due to proven efficacy (Gentile et al., 2006). This patient has been successfully treated with Adderall in the past so we recommended restarting Adderall. There are currently no contraindication to restarting a stimulant which he has tolerated before. We discussed restarting Adderall at 20mg XR daily and hopefully titrating upwards until last tolerated dosage. There may be a risk of cardiovascular effect due to potential increase in heart rate and blood pressure so we will monitor vitals vital signs regularly (Gentile et al., 2006). Genetic, environmental, and structural changes in the brain can play a role in ADHD (Curatolo et al, 2010). Deficiency in neurotransmitters dopamine and norepinephrine are implicated in ADHD. Adderall works by increasing norepinephrine and dopamine in certain regions of the brain such as the dorsolateral prefrontal cortex to improve attentiveness, concentration, and wakefulness (Stahl, 2017). Increased dopamine in the basal ganglia may also improve hyperactivity symptoms (Stahl, 2017). Patient was educated on risks versus benefits of prescribed medications, dose increases, and side effects to monitor for. Notable side effects of Adderall include insomnia, headache, dizziness, overstimulation, anorexia, abdominal pain, and tremors (Stahl, 2017). Supportive psychotherapy and behavioral interventions were recommended as well (Gentile et al., 2006). Frank (2021) noted pharmacological treatment for adjustment disorder with mixed symptoms include antidepressants and benzodiazepines. This patient has been on Lexapro which is managing his symptoms. Will continue Lexapro at 20mg daily. His next follow up appointment will be in 2 weeks or sooner if needed.

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