Reviewing the video- Psychiatric Interview and Mental Status Exam

Reviewing the video- Psychiatric Interview and Mental Status Exam

Patient Name: Georgianna Shea

MRN: 34

Date of Service:             11-25-2023

Start Time:                    10:00               End Time:                  10:25

Billing Code(s): 90832

Accompanied by:          Mother

CC: Underperformance in school.

HPI: The client’s grades have been falling every semester. He also added that he has been struggling in school for some time. Additionally, he does not conform to school norms such as taking notes, doing homework, or paying attention, and is only interested in gym activities and sports.

Subjective Findings: Findings revealed that the client seems to have considerable difficulties in his classwork. As revealed by his mother, he does not listen to his teachers and is forgetful, as demonstrated by his forgetting his books or class notes required to do his homework. He is also easily distracted and loses things easily. He is also disorganized, which places him at a crossroads with his mother. He also finds it difficult to complete tasks. These manifestations have been present for over a year. The client has no known allergies. He has specific interests in playing basketball and baseball and going to the gym. He reports liking outdoor activities that keep him engaged over classwork and other indoor activities. He has a negative history of mental health illness and mental healthcare. Additionally, he has never been hospitalized before. He denied taking any drugs or substances of abuse.

Objective findings 

Vitals: T 98.4, P 82, R 16, BP 122/78

Heart- R, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

MSE:

The client seemed alert and oriented to the place and event of the day. He answered questions appropriately when asked with a normal tone. He, however, seemed restless and avoided eye contact. His speech was normal. He denied suicidal ideation and or tendencies. He also denied experiencing auditory hallucinations. His memory was intact, as demonstrated by his ability to repeat a set of displayed words.

Differential Diagnoses:

Attention deficit hyperactive disorder with ICD 10 code F90. 0 denoting ADHD of predominantly inattentive type.

Depression with ICD 10 code F32.0

Generalized anxiety disorder with ICD code F41.1

Definitive Diagnosis:

Attention deficit hyperactive disorder ICD 10 code F90.0. This is specific for ADHD of predominantly inattentive type.

Plan

Comprehensive management of this client will utilize pharmacological and non-pharmacological interventions. Pharmacotherapy with drugs remains the mainstay modality for managing ADHD. Stimulant medications such as methylphenidates and amphetamines maintain effectiveness in alleviating the symptoms of ADHD (Kameg & Fradkin, 2021). They improve the concentration span of persons with these illnesses and enhance the cognitive functionalities of these individuals. The client, in the case presented, will be started on amphetamine 12.5 mg, taken every 24 hours.

Non-pharmacological interventions also maintain effectiveness in improving cognitive functionalities in persons with ADHD. Psychotherapeutic modalities such as cognitive behavioral therapy can help clients identify and correct negative thinking patterns that may be contributing to their illnesses. Adjunctive use of psychotherapy and pharmacotherapy in managing ADHD has been shown to produce superior clinical outcomes than either agent used alone (Strålin et al., 2022). For this reason, the client will be scheduled for 30-minute individualized and group CBT sessions. He will be reviewed after two weeks.

Patient Education

The client will be educated on the significance of adhering to his medications and counseling sessions. Additionally, he will be educated on the anticipated side effects of the medications he has been started on. Changes in blood pressure, loss of appetite, and sleep disturbances are the potential side effects of amphetamine. Referrals may be necessitated when the client fails to respond to these interventions.

References

Kameg, B., & Fradkin, D. (2021). Management of attention-deficit/hyperactivity disorder in adults. The Journal for Nurse Practitioners, 17(4), 432–436. https://doi.org/10.1016/j.nurpra.2020.11.005

Strålin, E. E., Thorell, L. B., Szybek, K., Lundgren, T., Bölte, S., & Bohman, B. (2022). Cognitive-behavioral group therapy for ADHD predominantly inattentive presentation: A feasibility study of a new treatment protocol. Nordic Psychology, 74(4), 325–339. https://doi.org/10.1080/19012276.2021.2020683

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Psychiatric Interview and Mental Status Exam

Review the video: Psychiatric Interview and Mental Status Exam

Using the readings, lecture, and references, write a complete SOAP note for this patient in the proper format as if this were a referral for you from the school counselor.

Post the SOAP note to this discussion board for your peer review.

Your post should include a comprehensive treatment plan which incorporates both psychosocial interventions as well as a medication plan, if indicated, with collateral information.

You may use the SOAP Note Template as a guide.