PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation

CC (chief complaint): “I do not see any does not see any benefits with my medications.”

HPI:

RR is a 21-year-old Asian male who presents for a follow-up visit for ADHD and medication management. He reports that he does not see any benefits with his medications, and the current Adderall medication makes him more tense. He states that he does not want to go the stimulant way. RR reports having increased anxiety and depressive symptoms. The client reports that he is still experiencing insomnia and he is too tired to work or engage in physical exercises. Besides, he states that he does not currently have a therapist but will work on having one when he starts school. However, he mentioned that he watches a lot of sports and spends time with his family.

Past Psychiatric History:

• General Statement: The client first presented for psychiatric evaluation due to ADHD.
• Caregivers (if applicable): None
• Hospitalizations: None
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: Rejection Sensitive Dysphoria

Substance Current Use and History: He denies drug substance use, smoking, or taking alcohol.

Family Psychiatric/Substance Use History: No history of psychiatric or SUDs in the family.  

Psychosocial History: RR lives with his parents and his younger sister. He is currently waiting to join university to study Theatre Arts. His hobbies include watching sports and acting, and he was a member of the Drama club in high school. He reports sleeping 3-4 hours daily with poor quality sleep due to insomnia.

Medical History:

• Current Medications: Adderall 5mg, guanfacine 1 mg, and Wellbutrin SR 100 mg daily.
• Allergies: None

• Reproductive Hx: No history of STIs.

ROS:

• GENERAL: Positive for increased fatigue. Denies fever, weight changes, or malaise.
• HEENT: Denies head injury, eye pain, excessive lacrimation, diplopia or blurred vision, ear pain/discharge, sneezing, nasal discharge, or pain when swallowing.
• SKIN: Negative for itching, rashes, or lesions.
• CARDIOVASCULAR: Denies dyspnea, edema, chest pain, or racing heart.
• RESPIRATORY: Denies cough, chest pain, wheezing, or difficulties in breathing.
• GASTROINTESTINAL: Denies abdominal distress, vomiting, or bowel changes.
• GENITOURINARY: Denies pelvic pain, dysuria, or blood in the urine.
• NEUROLOGICAL: Denies muscle weakness, paralysis, dizziness, or numbness.
• MUSCULOSKELETAL: Negative for limitations in movement.
• HEMATOLOGIC: Negative for bleeding or hx of anemia.
• LYMPHATICS: Denies lymph node swelling.
• ENDOCRINOLOGIC: No excessive perspiration, heat/cold intolerance, or polyuria.

Diagnostic results: No results available.

Assessment

Mental Status Examination:

Male client in his early 20’s. He is calm, alert, neat, and appropriately dressed. He maintains adequate eye contact and exhibits a positive attitude toward the clinician. The client has clear speech with normal rate and volume, and his thought process is goal-directed and logical. He denies auditory/visual hallucinations, homicidal ideations, or suicide ideations. No delusions, obsessions, or phobias were noted. His memory is intact, and he demonstrates good judgment.

Differential Diagnoses:

Attention Deficit Hyperactive Disorder (ADHD): ADHD manifests with impulsivity, hyperactivity, and inattention. Patients with the inattentive type are easily distracted, forgetful, disorganized, and do not follow instructions (Cabral et al., 2020). The patient had been previously diagnosed with ADHD and is on a follow-up visit. ADHD continues to be the primary diagnosis.

Generalized Anxiety Disorder (GAD): GAD presents with persistent and excessive anxiety or worries about everything. Other symptoms include restlessness, easy fatigue, concentration difficulties, muscle tension, irritability, and sleep disturbance (DeMartini et al., 2019). GAD is a likely diagnosis based on the client’s positive symptoms of fatigue, insomnia, and increased anxiety levels.

Major Depressive Disorder (MDD): MDD is a severe mood disorder that presents with persistent feelings of sadness and hopelessness and loss o