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Subjective
CH 53 yrs
Subjective note
REASON FOR EVALUATION/CONSULTATION/TREATMENT:. Psychiatric follow-up evaluation for medication management and supportive behavioral therapies..
SOURCES OF INFORMATION:. Patient. Chart.
RELEVANT LABORATORY/STUDY RESULTS:. None performed prior to this visit.
SCOPE OF INTERVIEW AND CONSENT: The patient was examined, the chart was reviewed; including all available medical notes, laboratory results, available imaging and current medication management. The Family/Patient/Staff was interviewed and collateral information was obtained. Treatment was provided (after obtaining informed consent), including supportive and behavioral therapies; medication review and management after assessing risks, benefits and alternative treatments. Patient/Responsible party understands risks, benefits and alternative treatments, the reasoning behind medications being chosen as well as how to take them and what to do and how to contact the physician and staff in an emergency situation.
HPI: Here for follow up of attention deficit and GAD.
“I’m doing really good and I don’t think I need the Adderall anymore. Maybe it’s because I’m getting older.” Following with endocrinologist Dr. Do regularly and PCP Dr. Meric. Will request labs to our office. Taking Armorall 110 mcg. Managing well with very infrequent Ativan use. Prefers to DC stimulant. Working great.” Reports stability in symptoms; mood noted to be good; energy is good. Acknowledges annual follow up with PCP and labs. Denies insomnia. Taking Armour Synthroid, Testosterone, benzo for emergencies. CURES checked
Objective
Objective note
RECENT MEDICAL HISTORY CHANGES: None. No issues with substance abuse, alcohol, tobacco or IVDA reported.
REVIEW OF SYSTEMS: Patient denies any GI related symptoms including nausea, vomiting, diarrhea or constipation. Patient also denies headaches as well as visual and hearing changes. Patient denies cough, chills or fever. Denies as well rashes, skin dryness or skin discoloration. Patient denies any urinary symptoms such as urgency, burning or frequency. The rest of the ten point review was unremarkable..
CLINICAL GLOBAL IMPRESSIONS – GLOBAL IMPROVEMENT (CGI-I). 4 = No change.
MENTAL STATUS EXAMINATION: Speech is normal, well modulated, with regular rate and rhythm. Patient is euthymic. Attitude is appropriate to this setting. Thought process is linear and goal directed. The patient’s perception of reality is normal with no delusions or hallucinations noted or reported. Patient is alert and oriented in all four spheres. The patient’s memory is intact. Attention span is intact. Reality testing is intact. Patient’s insight and judgment is intact. The patient appears calm and cooperative….
Observations
FUNCTIONAL STATUS
No functional status recorded
COGNITIVE STATUS
No cognitive status recorded
Assessment
Assessment note
DIAGNOSIS AS PER DSM V: H/o ADD and GAD
DECISION MAKING CAPABILITIES:. Patient is able to give informed consent. Patient has been educated and is aware of the diagnosis, prognosis as well as treatment plan.
Strengths:
1. Stable housing
2. Supportive primary support
Weaknesses:
1. Chronic disorder.
2. Weight management.
Screenings/Interventions/Assessments
No screenings/interventions/assessments recorded
Diagnoses attached to encounter
No diagnoses attached
Plan
Plan note
RECOMMENDATIONS AND TREATMENT PLAN:. Patient is stable . Not feeling need for Adderall and has self-stopped. POC as follows: 1. Disontinue Adderall 10 mg BID; not taking; self-stopped 2. Continue Ativan 0.5 mg PRN QOD extreme anxiety only. 10 tabs. Using intermittently.INFORMED CONSENT:. Informed consent has been obtained from the patient / responsible party. A full explanation of risks, benefits as well as alternative treatments has been given. We have reviewed black box warnings, special circumstances (i.e. driving/operation heavy machinery/avoiding combining with alcohol/sedating medications). FDA approved indications as well as off label use which is the standard of care in the community; special considerations for pregnancy and breast feeding if applicable, and is evidence based and the recommendations have been accepted for Ativan. THERAPY PROVIDED:Provided supportive, individual, psychotherapy, addressing individual’s identified treatment goals, utilizing a combination of cognitive-behavioral and insight-oriented modalities, as appropriate. Will continue to monitor for identified risk factors, and/or safety issues, medication compliance and side-effects. Psycho-educational services were provided to assist the patient to identify triggers and warning signs associated with a relapse of acute symptoms. Plan of care discussed with patient. RETURN TO CLINIC IN: 6 weeks or sooner if needed by pt. Will re-assess on next visit looking at efficacy and potential side effects.. ….
Medications/Prescription orders attached to encounter
No medications attached
Lab orders
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Imaging orders
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