Daniel DeMarco Focused H&P #2 Psychiatry

CC: Recently Discharged From Hospital for ARFID
HPI: 37 year old white male, married with two kids, not working by choice, domiciled, with a
reported past psych hx of social anxiety disorder and avoidant/restrictive food intake disorder
(ARFID), with a reported PMhx of Spontaneous Pneumothorax, Presented to Mindful Urgent
Care secondary to recent hospital discharge for ARFID and to establish psychiatric care. Patient
states he has been in cognitive behavioral therapy 1-2x per week for several years. His provider
is emphasizing beginning exposures but at this time the patient has not performed them.
Patient reports he suffers from debilitating social anxiety and ARFID. States that even thinking
about social situations gives him anxiety and that he is rarely able to attend dinners, parties,
etc. without experiencing panic attacks that manifest as rapid heart rate, sweating, palpitations.
Patient states that when thinking about social situations or knowing that he will need to be in a
social situation he will not eat until the event is over. Admits avoidant behaviors. Patient states
that he feels upset because of how his condition is affecting his life – it is particularly hard for
him that he cannot enjoy activities outside of the house with his children. Patient states on
8/19/19 he went to the ER as he had not had any food for four days. Patient states he was
extremely dehydrated. After stabilization, the patient was sent to New York Presbyterian in
Westchester for a total of 10 days inpatient stay. Patient reports he was required to eat his
meals in front of staff to ensure he was eating. At discharge he was placed on an eating
regimen which he has been compliant with. Reports that upon admission he weighed less than
100 lbs. The patient currently weighs 115 lbs. Patient was started on Escitalopram 10mg PO
qhs, Olanzapine 5mg PO qam, and Lorazepam 0.5mg PO bid prn. Patient reports he has been
compliant with the medications for three weeks and while he has not yet noticed an effect on
his anxiety symptoms, he has not experienced side effects. States that he tries not to take the
Lorazepam and saves it for emergencies. Patient states he has had anxiety for 18 years which
was when he was first prescribed Paroxetine and then another antidepressant. The patient
discontinued both in the past due to side effects. Admits social EtOH use with 1 drink per week
at most. Admits tobacco use: former 16 pack-year cigarette smoker. Currently uses an ecigarette every day x 2 years. Patient at this time denies active or passive thoughts of SI, with
no intent or plan. Patient adamantly denies any manic s/sx such as, racing thoughts, grandiose
beliefs, irritability, changes in or inappropriate social behaviors, elation, euphoria, unable to
focus, hyper sexual acts, hyper verbal speech pattern, decrease sleep pattern with increase in
energy. Patient adamantly denies ever attempting suicide in his life time and at this time denies
SI/HI/PI/AH/VH.
Past Psychiatric History: Social Anxiety Disorder, Avoidant/Restrictive Food Intake Disorder
(ARFID)
PMH: Spontaneous Pneumothorax
Past Surgical History: None
Allergies: NKDA
Medications:
Current: Escitalopram 10mg PO qhs, Olanzapine 5mg PO qam, Lorazepam 0.5mg PO bid
prn
Past: Paroxetine, Other Unknown Antidepressants
Health Maintenance:
Exercise: Not at this time. Patient states he needs to find out if he can begin an exercise
regimen as his care team wished for him to gain weight.
Sleep: 6-7h nightly
Diet: Prescribed Eating Regimen After Hospital Discharge
Sexual Activity: Sexually Active with Wife.
Immunizations: UTD
Social History:
Marital Status: Married
Living Situation: Domiciled with Wife and Two Children
Education and Employment: Employed as a Grocery Store Manager
EtOH/Drugs: Social EtOH use: 1 drink/weekly at most. Former 16 pack-year cigarette
smoker. Current daily E-Cigarette User x 2 years. Denies illicit drug use.
Family History:
Mother: Anxiety, Eating Disorder; Never Treated
ROS:
General: Admits weight gain
Mental Status Exam:
General
1. Appearance: Mr. M is a medium height, underweight white male who appeared his stated
age of 37yo. He has no scars on his face or hands. His hygienic state was clean and his clothes
well kept.
2. Behavior and Psychomotor Activity: Mr. M had no psychomotor agitation, retardation or
bizarre behavior.
3. Attitude Towards Examiner: Mr. M was pleasant and cooperated with the examiner. He
established rapport in about five minutes.
Sensorium and Cognition
1. Alertness and Consciousness: Mr. M was alert and could maintain his consciousness for the
entirety of the interview.
2. Orientation: Mr. M was oriented to person, place of the exam (Mindful Urgent Care), the
time of day (Morning) and date (9/9/19), and the situation (Recently discharged from hospital
for ARFID).
3. Concentration and Attention: Mr. M was attentive throughout the entirety of the interview.
He was able to concentrate and successfully complete the “Serial 7 Test.” Mr. M gave logical,
organized responses to questions. He did not stray to other topics.
4. Capacity to Read and Write: Mr. M demonstrated comprehension reading and writing.
5. Abstract Thinking: Mr. M used a few simple metaphors in English to explain things and clarify
his thoughts. He could mentally perform simple mathematical calculations including addition
(10 + 4 = 14), subtraction (9-5 = 4), and multiplication (1 x 100 = 100). His ability to recognize
patterns among groups of things was intact, answering “Red” when questioned what is the
same between a fire hydrant, an apple, and a stop sign? His ability to use deductive reasoning
was intact, answering “Bob’s cupboard has three shelves” when told the following facts: a) Bob
has a green cupboard b) All green cupboards have three shelves c) Lisa has a yellow cupboard,
and asked to draw a conclusion from the statements. When asked to interpret “Those who live
in a glass house should not throw stones,” the patient stated that it meant that people should
not criticize others because everybody has faults of their own.
6. Memory: Mr. M’s remote (Patient responded “Bayside” when asked where he lived when
growing up), recent (Patient responded ball, dog, and pencil when asked to recall the things I
asked him to remember 5 minutes prior), and immediate memory (Patient repeated ball, dog,
and pencil) were normal.
7. Fund of Information and Knowledge: Mr. M’s intellectual performance was normal (He
responded “Donald Trump” when asked who the president of the US was and “Albany” when
asked what the capital of NY is) and consistent with his level of employment (Grocery Store
Manager).
Mood and Affect
1. Mood: Mr. M’s mood was dysphoric.
2. Affect: Mr. M’s affect was flat.
3. Appropriateness: Mr. M’s mood and affect were consistent with the topics he discussed. He
did not exhibit labile emotions, angry outbursts, or uncontrollable crying.
Motor
1. Speech: Mr. M’s speech pattern was normal in rate, rhythm, articulation, and fluency.
2. Eye Contact: Mr. M made adequate eye contact.
3. Body Movements: Mr. M had no extremity tremors, facial tics, or decreased and slow body
movements. He had a normal gait.
Reasoning and Control
1. Impulse Control: Mr. M’s impulse control was satisfactory. He did not have suicidal or
homicidal urges.
2. Judgment: Mr. M had no paranoia, bizarre delusions, auditory or visual hallucinations. When
asked what the patient would do if he were sitting in a movie theater and there was a fire, he
responded “run.” When asked what he would do if he were to find a stamped, addressed
envelope on the sidewalk, he responded “pick it up and put it in the mailbox.”
3. Insight: Mr. M had fair insight into his psychiatric condition and the need to take medications
and attend therapy. When asked why he required psychiatric care he responded “I have social
anxiety and I avoid eating because of it – I was recently hospitalized because of this.”
Assessment/Plan:
JM is a 37yo Male with Past Psychiatric History of Social Anxiety Disorder and
Avoidant/Restrictive Food Intake Disorder (ARFID) reporting recent hospital admission and
subsequent discharge on Escitalopram, Olanzapine, and Lorazepam. His condition is improving
since discharge as evidenced by his weight gain, compliance with his medication and therapy,
and he is looking to establish care at Mindful Urgent Care.
#ARFID, Social Anxiety Disorder
– Refilled Escitalopram 10mg PO qhs
– Refilled Olanzapine 5mg PO qam
– Continue Lorazepam 0.5mg PO bid prn as directed by prescriber
– Continue Eating Regimen as directed
– Continue Therapy 1-2x/week as directed by Therapist
– Complete blood work as directed: CBC, CMP, TSH w/ Reflex T4
– Patient will inquire with care team about whether exercise regimen can be started
F/u in 4 wks
At this time, it is deemed that the patient does not pose a threat to self or others, and does not
present with any acute psychotic features. Patient is deemed psychiatrically stable and does not
merit further acute psych intervention. Patient is to be given a follow up appointment here at
Mindful Urgent Care upon d/c. The patient also displays adequate impulse control, insight and
judgement. SE and benefits > risks discussed with patient. Patient agreeable with tx plan.
/s/ Daniel DeMarco, PA-S
Physician Assistant Student
Differential Diagnosis:
1. Social Phobia: The patient has persistent (>6 months) intense fear of social situations.
Exposure to social situations provokes anxiety and causes panic attacks. The patient
realize the feelings are excessive and unreasonable, but engages in avoidant behaviors.
2. ARFID: The patient admits he avoids/restricts his food intake and has persistent failure to
meet nutritional and/or energy needs as evidenced by clinically significant weight loss
and impaired psychosocial functioning. The disturbance is not due to lack of available
food or culturally sanctioned practices, does not occur in the course of anorexia nervosa
or bulimia nervosa, and body weight and shape are not distorted.
3. Anorexia Nervosa (Restrictive Type): The patient has BMI < or = to 17.5 kg/m2 and
body weight <85% of ideal weight. However, the patient does not have a morbid fear of
fatness or gaining weight, making this diagnosis less likely.
4. Generalized Anxiety Disorder: The patient has excessive anxiety or worry a majority of
days for >6 months. The fact that his anxiety and worry is not about various aspects of
life, but rather is situational and focal, makes this diagnosis less likely.
5. Panic Disorder: The patient experiences recurrent panic attacks for >1 month. The fact
that his panic attacks occur as the result of a trigger, that he is not preoccupied by concern
of future attacks, that he has not had significant change in behavior related to the attacks,
make this diagnosis less likely.