Daniel DeMarco Focused H&P #5 Psychiatry

CC: Worsening Feelings of Depression

 

HPI: 22 year old white male, single, employed in father’s business, domiciled with father, with reported past psych hx of Major Depressive Disorder and Generalized Anxiety Disorder, with a reported PMhx of Celiac Disease and Lyme Disease, Presented to Mindful Urgent Care secondary to worsening feelings of depression x years and to establish psychiatric care. Pt admits feelings of isolation x whole life, anhedonia (exercise, social life), decreased libido, generalized anxiety, low confidence/self-esteem, and ruminating on intrusive, negative thoughts. Patient also witnessed a car accident last year which he frequently thinks about. Patient states he experiences brief periods of happiness but often feels that things “won’t get better” and states that he needs a chang.  He often feels “stuck,” generally unhappy, and irritable. Has been in therapy a few years ago which he felt was not helping and was also started on Sertraline 5yrs ago by his Pediatrician which he only took for 3 days as it made him feel “like a robot.” Recently started therapy with Diane Sweet who referred him here and he states that things are going well. Patient admits that he was using marijuana daily x years. He is trying to cut back. Patient’s older brother is diagnosed with depression which is being treated with 200mg Sertraline q daily and 25mg Lamotrigine q daily. Pt admits to having fleeting thoughts of passive suicidal ideation with no intent or plan. Patient at this time denies active thoughts of SI. 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, denies ever being hospitalized for mental health issues, and at this time denies active SI/HI/PI/AH/Vh or drug use other than marijuana and etoh use.

 

Past Psychiatric History: Major Depressive Disorder, Generalized Anxiety Disorder

PMH: Celiac Disease, Lyme Disease

Past Surgical History: None

Allergies: NKDA

Medications:

Current: None

Past: Zoloft

Health Maintenance:

Exercise: 3-4x weekly; aerobic and anaerobic

Sleep: 6-7h nightly

Diet: Gluten-Free

Sexual Activity: Not sexually active at this time

Immunizations: UTD

Social History:

Marital Status: Single

Living Situation: Domiciled with Father

Education and Employment: B.S. in Corporate Entrepreneurship from Penn State 2018, 

Employed at his father’s company

EtOH/Drugs: Occasional EtOH use. Former daily Marijuana smoker.

Family History:

Brother: Depression treated with 200mg Sertraline qd and 25mg Lamotrigine qd

 

ROS:

General: Denies fever, chills, anorexia, weight loss, weight gain

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny 

nose, ear pain, congestion, sore throat

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, 

palpitations, history of murmur, fainting, or dizziness with activity 

Respiratory: Denies wheezing, shortness of breath, cough

GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis, 

hematochezia, or melena

GU: Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Denies rashes, bruising, petechiae

Psychiatric: Admits feelings of helplessness, hopelessness, passive SI. Denies HI, active 

SI, auditory hallucinations, visual hallucinations, paranoia

 

Mental Status Exam:

General

 

1. Appearance: Mr. M is a medium height, thin white male who appeared his stated age of 22yo. 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 cooperated with the examiner and he established rapport in about three 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, the time of day and date, and the situation.

 

3. Concentration and Attention: Mr. M was attentive throughout the entirety of the interview. Mr. M gave relevant responses to questions. 

 

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. His ability to use deductive reasoning was intact.

 

6. Memory: Mr. M’s remote, recent, and immediate memory were normal.

 

7. Fund of Information and Knowledge: Mr. M’s intellectual performance was normal and consistent with his level of education (Bachelor’s Degree in Corporate Entrepreneurship).

 

Mood and Affect 

 

1. Mood: Mr. M’s mood was dysphoric.

 

2. Affect: Mr. M’s affect was restricted.

 

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 active suicidal or homicidal urges. 

 

2. Judgment: Mr. M had no paranoia, bizarre delusions, auditory or visual hallucinations. 

 

3. Insight: Mr. M had fair insight into his psychiatric condition and the need to take medications and attend therapy.

 

Assessment/Plan:

MM is a 22yo Male with Past Psychiatric History of MDD and GAD complaining of isolation, anhedonia, decreased libido, rumination, and passive suicidal ideation consistent with recurrence of MDD.

 

#MDD, GAD

– Start Escitalopram 5mg PO qd

– Continue weekly therapy with Diane Sweet as directed

– Complete blood work as directed: CBC, CMP, TSH w/ Reflex T4

– Continue exercise regimen

 

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. At this time, the patient does not present an immediate threat to self or others. 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