Psychiatric evaluation
Order Instructions
Respond to the following psych evaluation. Why do you agree/disagree?
Patient is a 52-year-old Caucasian male who presents to the clinic to establish care; his account is reliable.
SUBJECTIVE DATA
HISTORY OF PRESENT ILLNESS
The patient is a 52 y/o Caucasian male who reports a history of ADHD (Attention-Deficit Hyperactivity Disorder). He notes that he experienced hyperactivity, impulsivity, and inattention when he was younger which, in turn, resulted in a myriad of learning problems including increased absenteeism and poor academic performance, especially in college. Additionally, his inability to accurately internalize social cues and remain attentive during conversations resulted in strained relationships with his peers. These challenges were such a hindrance in the pt’s daily life that he eventually dropped out of college and sought medical assistance. After multiple clinical assessments, he was diagnosed with ADHD and prescribed Dextroamphetamine-amphetamine as well as Adderall. He also attended CBT (Cognitive Behavioral Therapy) sessions for the first twenty-four months of treatment. The patient states that his executive functions have tremendously improved over time, allowing him to improve all aspects of his life. He is currently employed as a property manager; a job that he loves, and lives a fully-functioning, self-sufficient life. He has no history of suicidal or homicidal ideations, denies delusional introspections, and has no access to any deadly weapons.
PAST PSYCHIATRIC HISTORY
The patient previously followed with a psychiatrist as a teenager after exhibiting heightened restlessness, inattention, and impulsivity. He was initially diagnosed with ADHD, combined presentation, and prescribed Adderall 20 mg and Dextroamphetamine-amphetamine 30 mg. He also attended CBT sessions for the first two years of treatment in which he underwent intense talk therapy that focused on improving his emotional and behavioral responses to all forms of psychological distress. He is currently taking Adderall and stopped taking Dextroamphetamine-amphetamine in November 2020. His executive functions have greatly improved thanks to medications and structured periods.
PREVIOUS PSYCHIATRIC MEDICATIONS
Dexedrine 30 mg
CURRENT PSYCHIATRIC MEDICATION
Adderall 20 mg
SUBSTANCE ABUSE/ADDICTIVE BEHAVIORS
The patient reports smoking around half a pack of cigarettes daily. He denies any alcohol or any illicit substance use.
FAMILY PSYCHIATRIC HISTORY
The patient denies any family psychiatric history, denies h/o suicidal tendencies or drug abuse.
MEDICAL HISTORY
The patient denies any surgical or medical history. He reports no history of supplement use, no history of eating disorders, and no history of over the counter drug consumption.
ALLERGIES
Patient denies any medication, environmental, or food allergies.
LEGAL HISTORY
No legal history.
REVIEW OF SYSTEMS
General: Negative for night sweats, unintentional weight loss, unintentional weight gain, inflammation, fever.
HEENT: Negative for hearing loss, headaches, epistaxis, vision loss.
Cardiovascular: Negative for palpitations, chest pain, or irregular heart rate.
Respiratory: Negative for irregular breathing, shortness of breath, coughs, or wheezing.
Skin/Nails/Hair: Negative for alterations in nail or hair color, dryness, or skin rash.
Gastrointestinal: Negative for abdominal pain, puking, dysentery, constipation, or nausea.
Neuromuscular: Negative for joint edema, changes in memory or coordination capabilities, fatigue, joint pain, or recent injuries.
PSYCHOSOCIAL
The patient is a heterosexual adult male living a socially and financially stable life. He was born and raised in Idaho. He is the eldest of four and has two brothers and one sister. He is still very close with his siblings and mother. Unfortunately, his father passed away when he was seventeen years old. He has a wife to whom he has been happily married for 23 years and they are blessed with a 21-year-old son. The patient dropped out of college after three semesters due to medical issues relating to his ADHD. He has been on medication ever since and this has greatly helped him regain control of his life. He is currently employed as a property manager in Boston and aspires to own his own rental property in the future. His family is fully aware of his condition and they are very supportive. The patient loves spending his weekends at home watching the New England Patriots with his son. He reports having steady sleep patterns and a good appetite. The subject denies any previous military service, any form of sexual or domestic violence, or legal issues. He is a practicing Catholic and regularly attends mass on Sunday with his family.
ASSETS/STRESSOR
ASSETS: Patient loves spending time with his family over the weekends and tending to his work duties during weekdays. This routine gives his life a proper structure.
STRESSORS:
Patient might not be able to cope without structured periods and medication.
OBJECTIVE DATA
HT: 5’9’’
WT: 207.4 lbs.
PHQ-9: 3
BMI: 26.2
UDS: Negative for alcohol or illegal drugs
MENTAL STATUS EXAMINATION
The patient is attentive and oriented to place, situation, time, and person. He is neatly dressed, responds to questions appropriately, interacts pleasantly, his mood is euthymic, his intelligence is average, he speaks fluently and in normal volume, is cooperative, and maintains a calm demeanor. He also maintains appropriate eye contact and his thoughts are congruent and logical. His motor activity is intact with a logical process that is goal oriented and his judgment is intact. His memory and insight are also good. The patient is evidently enthusiastic about his medication and shows no evidence of homicidal, suicidal, or any kind of violent ideations.
ASSESSMENT
DIFFERENTIAL
F84.5 Asperger’s Syndrome
Asperger’s syndrome is a developmental disorder that affects an individual’s ability to communicate and socialize appropriately. It is currently a part of the autism spectrum, albeit with more effective functioning (Loskutova, Callen, & Lutgen, 2019). This condition is largely characterized by inattentiveness and heightened social awkwardness that prevents individuals from effectively socializing. Individuals with Asperger’s Syndrome also suffer from poor coordination of muscle movements which, in turn, causes irregular tics. Their mood is mostly apprehensive or anxious and they experience impulsivity, extensive periods of solitude, and an incessant repetition of movements or articulations (Loskutova, Callen, & Lutgen, 2019).
DIAGNOSIS IMPRESSION WITH FORMULATION
F90.2 Attention Deficit Hyperactivity Disorder, Combined Type
ADHD, combined type is a persistent neurodevelopmental disorder that is characterized by functional and structural brain anomalies (Mahone & Denckla, 2017). It is typically characterized by significant inattentiveness, hyperactivity, and impulsive tendencies. According to DSM-5 criteria, patients with this condition display poor listening skills and are often poor conversationalists as they tend to be unable to wait their turn during conversations and have difficulty accurately interpreting social cues. Individuals with ADHD, combined type are also often restless, have a diminished attention span, and lack the ability to focus on a single item as they are easily sidetracked by external stimuli (Mahone & Denckla, 2017). Per DSM-5 criteria, individuals must exhibit hyperactive and inattentive criteria for at least 6 months and in at least two settings in order to be diagnosed with ADHD, combined type. In this case, the patient exhibits both inattentive and impulsive tendencies, and has suffered from the condition from a young age. Moreover, his condition is not an exclusive manifestation of oppositional deportment. Of note, he has responded exceptionally well to medications and, thus, is able to live a well-coordinated, self-sufficient life. There is, however, a significant risk that the patient will suffer from withdrawal and his ADHD symptoms will be exacerbated if he stops taking his medication (NICE, 2018).
RISK ASSESSMENT
The subject denies past or present suicidal or homicidal ideations.
RECOMMENDATIONS/PLAN/GOALS/RATIONALES WITH NEUROBIOLOGY
Continue Adderall 20 mg. The subject will continue taking one tablet, three times daily by oral route, for one month. This is an FDA approved CNS stimulant that helps to enhance the patient’s focus, attention, and minimize impulsive tendencies (NICE, 2018).
Patient will follow up with the clinic after four weeks.
Patient education will tackle drug risks including serotonin syndrome and addiction. Therefore, he is advised to stick to the prescribed dosage, to avoid alcohol, and never to share his medicine.
Patient verbalized understanding and agreement of all treatment recommendations.
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