Focused H&P #6

Daniel DeMarco Focused H&P #6 Psychiatry

CC: “Losing Focus” and “Feeling Out of It”

 

HPI: 27 year old African American male, single, employed, domiciled, with a reported past psych hx of ADHD Presented to Mindful Urgent Care secondary to “Losing Focus” and “Feeling Out Of It” and to establish psychiatric care. Pt states that he was previously diagnosed with ADHD in the 7th grade for which he was prescribed Methylphenidate and saw a school counselor. Pt’s mother discontinued the medication when the patient went to high school as she “no longer wanted him taking it.” Pt states that he was able to manage his symptoms throughout high school and his undergraduate education. He just completed his Masters Program in Social Work where he found his symptoms were slightly interfering with his education over the past year. He states he had difficulty getting started doing work, remaining attentive to the task at hand, and often found that he was rushing to complete the schoolwork at the last minute. Pt states that over the year the symptoms have been worsening and now that he is employed he finds that he is unable to concentrate for the full work day and worries about his productivity. Patient also states that he sometimes worries about his student loan debt, but not to the point of impacting day to day living. Patient states that he sleeps regularly between 10PM and 4:30AM but admits to occasional nighttime awakening and is aware that he snores. Patient endorses regular exercise and states his appetite has been the same. EKG from 5/25/19 normal per patient. 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, 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 SI/HI/PI/AH/Vh or illicit drug use. 

 

Past Psychiatric History: ADHD diagnosed in 7th/8th grade

PMH: None

Past Surgical History: None

Allergies: NKDA

Medications:

Current: None

Past: Methylphenidate

Health Maintenance:

Exercise: Daily; aerobic and anaerobic

Sleep: 6.5h nightly

Diet: Varied

Sexual Activity: Sexually Active

Immunizations: UTD

Social History:

Marital Status: Single

Living Situation: Domiciled with mother and father

Education and Employment: M.S. in Social Work, Social Worker at New Horizon, 

Trainer/Therapist at CrossFit Gym

EtOH/Drugs: Occasional EtOH use. No illicit drug use.

Family History: None

 

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: Denies feelings of helplessness, hopelessness, passive or active SI, auditory 

hallucinations, visual hallucinations, paranoia

 

Mental Status Exam:

General

 

  1. Appearance: Mr. B is an above average height, medium build African American male who appeared his stated age of 27yo. 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. B had no psychomotor agitation, retardation or bizarre behavior.

 

  1. Attitude Towards Examiner: Mr. B cooperated with the examiner and he established rapport in about three minutes. 

 

Sensorium and Cognition 

 

  1. Alertness and Consciousness: Mr. B was alert and could maintain his consciousness for the entirety of the interview. 

 

  1. Orientation: Mr. B was oriented to person, place of the exam, the time of day and date, and the situation.

 

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

 

  1. Capacity to Read and Write: Mr. B demonstrated comprehension reading and writing.

 

  1. Abstract Thinking: Mr. B 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.

 

  1. Memory: Mr. B’s remote, recent, and immediate memory were normal.

 

  1. Fund of Information and Knowledge: Mr. B’s intellectual performance was normal and consistent with his level of education (Master’s in Social Work).

 

Mood and Affect 

 

  1. Mood: Mr. B’s mood was euthymic.

 

  1. Affect: Mr. B’s affect was normal.

 

  1. Appropriateness: Mr. B’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. B’s speech pattern was normal in rate, rhythm, articulation, and fluency.

 

  1. Eye Contact: Mr. B made adequate eye contact. 

 

  1. Body Movements: Mr. B had no extremity tremors, facial tics, or decreased and slow body movements. He had a normal gait.

 

Reasoning and Control

 

  1. Impulse Control: Mr. B’s impulse control was satisfactory. He did not have suicidal or homicidal urges. 

 

  1. Judgment: Mr. B had no paranoia, bizarre delusions, auditory or visual hallucinations. 

 

  1. Insight: Mr. B had fair insight into his psychiatric condition and the need to take medication.

 

Assessment/Plan:

CB is a 27yo Male with Past Psychiatric History of ADHD complaining of inattention, difficulty starting activities, and “losing focus” consistent with ADHD.

 

#ADHD

– Start Atomoxetine 40mg PO qd

– 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