Problem:
Write a follow up psychiatric note, chief complaint, current Meds, HPI, formulation, recommendation treatment plan for a 49 years old male with diagnosis of Obsessive-compulsive disorder unspecified, Major depressive disorder, Recurrent episode Moderate, Mental disorder not otherwise specified, Attention-deficit/hyperactivity disorder, Combined presentation and Generalized anxiety disorder Chief Compliant: Follow up psychiatric visit and medication refills Current Meds: FLUoxetine 40 mg capsule daily, gabapentin 300 mg capsule BID for anxiety HPI: He said he is doing ok but was not able to refill his Gabapentin from his last provider. He also said he is thinking not to continue taking his Gabapentin. He said he was taking Gabapentin 300mg BID to mange his anxiety and improve his sleep. He said he has been out of Gabapentin about 2 to 3weeks form now and he is really noticing the difference. He said he has been on Lamotrigine 150mg daily but he was not taking it consistently but recently he has started taking it consistently and has only missed one dose in the past 3weeks. He said he loves reading books and has a good memory in the books , however he is not able to remember what he took for dinner few days ago. Patient said he loves reading and would like to explore treatment options for his ADHD. He said he has never taken medications for his ADHD because he always loved explore treatment options , he said when watching a movie, if he is alone he will be turning off the tv. Need Assignment Help?