Description
CC
Psychiatric evaluation and medication management
F/U on management of ADHD symptoms
Subjective
History of Present Illness (HPI): ADHD
12-year-old male is seen today for psychiatric evaluation and medication management via telepsychiatry videoconferencing. The patient is accompanied by his mother. He has good eye contact patient, and his mother reports that the patient has not been on Qelbree for more than 4 months and says the patient continue top do well without medication. His appetite is good. He reports sleeping well. He does wake up at night but falls back easily. He is riding his bike for exercise. Encouraged him to talk to his mother about any questions or concerns that may come up. He verbalizes he will. Denies questions at this time. Mom and patient agree to discontinue the medication now to evaluate any changes from him discontinuing the medication while he is only in summer school. The patient and his mother report that the patient’s anxiety, ADHD symptoms, and depressive symptoms are all well-managed. Denies auditory and visual hallucinations. Denies suicidal and homicidal ideation during today’s encounter. Follow-up in three months.
Rx: Discontinue Qellbree 150 mg QHS follow-up in 3 months; if still doing well, he will be discharged.
Medication Compliance: N/A
Side Effects: no
Appetite: Good
Sleep: Good
Medications
viloxazine ER 150 mg capsule,extended release 24 hr, Take 150mg PO Daily (Edited by LAWRENCE ABAH on 14 Jun, 2023 at 03:55 PM )
viloxazine ER 150 mg capsule,extended release 24 hr, take 150mg (2 tablets) daily (Edited by LAWRENCE ABAH on 14 Mar, 2023 at 04:23 PM )
Allergies
No allergy history has been documented for this patient.
Mental/Functional
Functional Finding: able to bath self, independent with dressing, able to feed self, independent in toilet and transfer independent.
Cognitive Function Finding: oriented to person, time and place, able to use decision making strategies, memory: own age known, able to direct attention and able to read.
Objective
Mental Status Exam:Demeanor: Pleasant during interview
Orientation: Oriented to self, place, and time
Behavior: Cooperative with exam
Speech: Speech is fluent
Mood: “6/10” where 10 is feeling best
Affect: Appropriate to situation
Thought Process: Goal directed
Thought Content: Denies auditory hallucinations. Denies visual hallucination.
Suicidal Ideation: Denied
Homicidal Ideation: Denied
Memory: GOOD
Sleep: GOOD .
Appetite: GOOD .
Anxiety: 6/10, verbalized being anxious
Perceptual disturbances: Denies auditory hallucination, denies visual hallucination
Insight: Good
Judgment: Good; does understand why he was interviewed
Concentration: Fair
Focus: GOOD
Assessment
AssessmentDiagnosis:
1. ADHD
2. Anxiety D/O
Past Psychiatric History: YES
1. Suicide Attempts: no
2. Hospitalizations: no
3. Medications: no
4. Family History: YES
Available records from past year/hospital reviewed: yes
Medical History: Refer to medical reports.
Allergies: NKDA
Review of Systems:
Refer to medical reports
Additional Work Up:
1. Collateral information from primary care doctor and/or chart: yes
2. Collateral information from family: no
3. Educate patient on treatment plan: yes
4. Labs Reviewed: No
Plan
Treatment Plan:1. Risk Assessment: Patient is not in current danger to self or others
2. Medications:
-Continue with therapy.
3. Side effects / risks / benefits of medications explained to patient
4. Patient notified that if condition worsens, she should notify office
5. Patient understood and agreed with above plan
6. Spent 30 mins on individual psychotherapy during this visit.
Recommended follow-up: Routine: Discha
