Patient Initials: CJ
Clinical Site:
Identifying Information:
CHIEF COMPLIANT/HISTORY OF PRESENT ILLNESS: Mother
(What is the patient saying? Quote the patient if possible)
Behavior: Disruptive and impulsive
Depressive symptoms: Detected
Anxiety symptoms: Detected
Psychotic symptoms: Absent
Vegetative symptoms: Absent as patient is motile
Suicidal ideation: Absent
Homicidal ideation: Absent
Compliance: Intermittent
Cognitive symptoms: Not consistent with incidences of forgetfulness
History of any mania in the past: None
Sleeping patterns: Short sleeping hours less than 5 hours a day
Appetite: Highly selective
(Including any significant weight loss or weight gain)
PREVIOUS PSYCHIATRIC HISTORY
(Including any previous psychiatric hospital admissions): None
Any past suicide attempts: None
Failed medications: None tried before
PREVIOUS PSYCHIATRIC FAMILY HISTORY:
(Including any diagnosed psychiatric illness, suicide attempts or completion, and/or substance abuse): Paternal grandmother diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)
SOCIAL HISTORY
Marital status: Not married
Children: None
Substance abuse history: None
Education: Senior high school
Military history: None
Work history: None
Abuse (sexual/physical/verbal) history: None
Substance Use: ETOH, Tobacco, Caffeine, Cocaine, Marijuana,
Opiods, Crack, Heroin, LSD, Other_______None_______
Source of income:
MEDICAL HISTORY
Past Medical History: Attention Deficit Hyperactivity Disorder (ADHD) diagnosis
Current Medical Diagnoses: Repeated Asthmatic Attacks
Medications: Atomoxetine pharmacological therapy
Allergies: Pollen hyperactivity
MENTAL STATUS EXAM:
Appearance: Normal
Speech: Normal
Mood/affect: Range between periods of extreme quietness to periods of impulsive behavior
Behavior: Sometimes very quiet and withdrawn but sometimes very Disruptive and impulsive
Thought process: Random
Thought content: Poor
Orientation: Appears normal
Judgment: Sometimes very irrational
Insight: Poor
Attention: Not consistent with several incidences of deficits
Cognitive function: Intermittent
Folstein MMSE: Slight cognitive impairment
Reliability: Not reliable
SCREENING TOOLS AND RESULTS: Conner Adult ___, Conner Adolescent_yes_, AIMS____, MDQ____, Clock Test____,
Beck Depression____, Beck Anxiety_____, Other_________________
OTHER ASSESSMENT INFORMATION: B/P: _ 128/85 mm Hg __, Pulse: 118 beats/minute ____, Resp:_ 22 breaths/min, ___, Temp:_ 37.2° C ___, Height_150cm___, Weight_50kgs___, Waist Circumference_32 cm___, BMI_20_____, gait__Normal ____
Labs ordered and results (include rationale for ordering): None
DIFFERENTIAL DIAGNOSES:
(Including Psychiatric and Medical)
IDENTIFIED PROBLEMS:
Problem 1: Severe asthma attack
Expected outcome: Reduced impacts of asthma attacks
Problem 2: Attention Deficit Hyperactivity Disorder
Expected outcome: Reducing the impacts of Attention Deficit Hyperactivity Disorder
Problem 3:
Expected outcome
Problem 4:
Expected outcome:
TREATMENT PLAN (Including Medications, Follow up, Therapy recommendations, hospitalization):
As part of the treatment plan, there was a recommendation of the pharmacological combination of the stimulant Methylphenidate and the non-stimulant Atomoxetine. There was also a prescription of steroids and leukotriene modifiers coupled with immunomodulators to manage the severe asthmatic attacks. Atomoxetine would also help in combating asthama.
RATIONALE FOR TREATMENT PLAN:
The impacts of the stimulant in increasing the brain’s norepinephrine concentration and dopamine concentration to increase cognitive abilities of the individual
PROGNOSIS:
Psychiatric Progress Notes
Response to therapy/medications since last visit:
Mental Status exam:
Appearance: Normal
Speech: Normal
Mood/affect: Stable
Behavior: Normal
Thought process: Stable
Thought content: Insightful
Orientation: Normal
Judgment: Consistently rational
Insight: Improved
Attention: Constant
Cognitive function:Normal
Folstein MMSE: No notable cognitive impairment
Reliability: Increased
Suicidal or Homicidal Ideations/intent or plan: None
Changes to non-psych medications, environment, or other relevant areas since last visit: None
Progress on identified problems from psych eval: Improved
Revisions to treatment plan: Not necessary
