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Chief Complaint: The patient is seen for initial medication assessment with complaint of “I was diagnosed with ADHD as a child, but never got treated and I am struggling at this time”


Biopsychosocial Assessment : Age, ethnicity, religion, marital status, etc.

The patient is a 33 years old African American Male , Single


History of Present Illness:

The patient reports he was always in trouble as a child and

growing up was not easy. The patient reports he has been struggling with depression since having twins.


The patient endorses depressive symptoms, including

sleep alteration, loss of interest in pleasurable activities,

feelings of guilt/worthlessness/hopelessness, problems

with energy, problems with concentration, appetite

disturbance. Patient denies suicidal and homicidal ideation.


The patient endorses symptoms of generalized anxiety,

including excessive worrying throughout the day,

associated with, restlessness, easy fatigability, difficulty

concentration, irritability, muscle tension and disrupted


The patient endorses symptoms of inattentiveness

including having a short attention span and being easily

distracted, making mistakes, in work or at school,

appearing forgetful or losing things, being unable to stick

to tasks that are tedious or time-consuming, appearing to

be unable to listen to or carry out instructions, constantly

changing activity or task, having difficulty organizing


The patient endorses symptoms of hyperactivity and

impulsiveness including being unable to sit still, especially

in calm or quiet surroundings, constantly fidgeting, being

unable to concentrate on tasks, excessive physical

movement, excessive talking, being unable to wait their

turn, acting without thinking, interrupting conversations,

little or no sense of danger.


Psychiatric History

The patient reports prior diagnosis of ADHD


Trauma History : Type, person involved

The patient reports he struggle as a child and went through a lot of traumatic situations. The patient reports they moved from


Family Psychiatric History

Brother -Anxiety, depression, PTSD

Father – Drug dealer

Mother – Depression


Substance Use


Marijuana: NO


Alcohol: NO


Tobacco: NO


Caffeine: YES


Other: NO


Social History

The patient reports

Patient denied suicidal ideation:

The patient denied


Education/Vocational History

High School / Employed


Religious / Spiritual Involvement:

Religious / Spiritual Involvement: The patient denied

Risk Assessment


Suicidal Ideation


Homicidal Ideation



General Appearance: Appears Stated Age

HEENT: PERRLA, Normocephalic, Atramatic

Neck: Supple, FROM, and no masses or goiter on Thyroid

Cardiovascular: RRR

Respiratory: CTA, Equal Breath Sounds and Chest Expansion

Abdomen: Soft, Non-Tender, BS x 4

Neurologic: Cranial Nerves II – XII grossly intact and no focal neuro deficits

Extremities: Within Normal Limits

Spine: Within Normal Limits


Grooming and Appearance:

Grooming and Appearance: Neatly dressed, Well groomed

Eye Contact:

Eye Contact: Direct

Psychomotor Behavior:

Psychomotor Behavior: Fine Motor-WNL, Gross Motor-WNL


Speech: Normal rate and volume


Language: Coherent


Cooperation: Cooperative


Attitude: Appropriate

Cognition Attention Span and Concentration:

Attention Span and Concentration: Alert, Intact

Past Medical History:

Illness, Injuries, Operations, and Treatments: None

Orientation to Time, Place, and Person:

Orientation to Time, Place, and Person: Oriented X4

Recent Memory:

Recent Memory: Intact

Remote Memory:

Remote Memory: Intact

Fund of Knowledge:

Fund of Knowledge: WNL

Emotional State Mood:

Mood: Happy


Affect: Alert


Appropriateness: Appropriate to the situation

Judgment and Insight Judgment:

Judgement: WNL


Insight: WNL

Thought Processes Rate:

Rate: Normal Rate and Rhythm

Abstract Reasoning:

Abstract Reasoning: Intact


Associations: Intact


Computation: Able to complete complex computation


Content: Clear, Logical

Abnormal or Psychotic Thoughts:

Abnormal or Psychotic Thoughts: None

Past Medical History

Current Symptoms and Problems: No Known Allergies

Current Medications:

Current Medications: No current medications on file

Past Medication and Side Effects:

Medication Reactions and Side Effects: None


Treatment Plan: Start Zoloft 50mg daily for anxiety and depression. Follow up in a month.

Medication Management

Current Medications: -Drug Name: sertraline, Strength: 50 mg, Directions: Take half a tablet by mouth daily for two week and then take one tablet by mouth daily after. Form: tablet.

-Drug Name: atomoxetine, Strength: 18 mg, Directions: Take one tablet by mouth daily in the morning. Form: capsule.

Clinical Assessment and Treatment Plan:

Clinical Assessment and Treatment Plan: The patient current symptoms is consistent with anxiety and ADHD. The patient seem to be going through life changes making it hard for him to control his ADHD and anxiety symptoms which he has been doing well in the past.

90792 – Psychiatric diagnostic evaluation with medical services:

90785 – Interactive Complexity is an add-on code:

96127-Behavioral Assessment:


Patient/Medication Education

Patient/Change Medical Plan

Reasons for Modifications or Continuation of Current Medications in Plan: • Patient educated about symptoms, illness, and diagnosis. Treatment options reviewed. Patient verbalized understanding and agreement with treatment plan/recommendations.


• Advised routine follow-up with PCP with lab testing. Discussed potential medical causes of current symptoms and importance for additional testing with PCP as needed.


• Discussed benefits, risks, and side effect profile of medication/s with the patient. They verbalized willingness to take the medication/s as prescribed. Counseled the patient on the importance of medication compliance and to not discontinue medications without medical advice as withdrawal symptoms and/ or worsening of symptoms may occur.


• Antidepressants: the patient was informed of possible adverse effects including, but not limited to weight gain, headaches, dizziness, nausea/vomiting, abdominal pain, diarrhea/constipation, tremors, muscle pain/aches. This includes black box warning of emergence of suicidal ideations. The patient expressed understanding. Alternatives to this medication were also discussed with the patient, including risks of not taking medications, and the patient was agreeable to the above choice.


• Antipsychotics: the patient was informed of possible adverse effects including, but not limited to akathisia, extrapyramidal symptoms, dystonia, drowsiness, and long-term concerns for tardive dyskinesia, weight gain, insulin resistance, dyslipidemia, and cognitive slowing. The patient expressed understanding.

Alternatives to this medication were also discussed with the patient, including risks of not taking medications, and the patient was agreeable to the above choice.


• Benzodiazepines: Discussed and educated the patient that benzodiazepines are generally not intended for prolonged use. They are likely to cause tolerance and dependence over time, and can cause disinhibition, cognitive impairment, and increase risk of falls. They are not recommended to be used concurrently with narcotics, hypnotics, and/or other benzodiazepines, as they also increase the risk of profound sedation, respiratory depression, coma, and even death. They are also not to be used with any alcohol for the same reasons. A plan to taper benzodiazepines over time was also discussed, along with options for alternative anxiolytics intended to be suitable replacements.


• Stimulants: May cause increase blood pressure and heart rate, may cause psychotropic or manic symptoms in patient with no prior history or increase in patient with preexisting psychiatric illness. have been associated with weight loss and slowing of growth rate in children (Monitor Height and weight accordingly). May result in peripheral vasculopathy and Raynaud is phenomenon. May cause increase agitation, anxiety, headache, insomnia, loss of appetite and nervousness.


• Patient advised to avoid driving or operating heavy machinery until the patient is aware of how

medication affects him/her and feels can perform those functions safely.

• The patient was encouraged to spend time with family and friends who the patient is comfortable spending time with. Pt educated on the value of regular exercise in regulating mood and the importance of eating a healthy and balanced nutrition to enhance well-being.


• Patient advised against using alcohol and/or illicit substances while on psychotropic medication due to risk of negative interactions and is aware doing so will be at his/her own risk.


• Patient advised to call 9-1-1 or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal or homicidal ideation or plans.

Patient Understands and Agrees with Treatment Plan

Patient Understands They May Call at Any Time Prior to the Next Appointment



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