Problem
Demographics: 23-year-old single white nonbinary pt assigned female at birth, who uses They/Them pronouns, from Cincinnati, Ohio, pt is a full time undergraduate student at Stanford, getting a bachelor`s degree in International Studies.
Chief Concern: Pt needs medication management as they are almost out of their psychotropic medication.
History of Present Illness: Pt was diagnosed with MDD, OCD and ADHD, they currently see a therapist weekly for symptom management and need a provider to manage their medication, their depression and OCD symptoms have been under control, however, they have been struggling with inattention and distractibility for the last month.
Past Medical History: ADHD, MDD, OCD and long Covid 19
Medication History: Abilify 5 mg PO QHS, Prozac 40 mg and Wellbutrin XL PO QAM
Family History: "Mom has bipolar, anxiety, adhd and depression; dad and both sisters have anxiety, depression, and adhd".
Social History: 23-year-old single white non binary pt assigned female at birth, who uses They/Them pronouns, from Cincinnati, Ohio, pt is a full time undergraduate student at Stanford, getting a bachelor`s degree in International Studies. They are in their last year before graduating, they intend to join the workforce right after school, they are not planning to pursue their master's at the moment. They had social anxiety, depressive and inattentive symptoms since High school, they used to spend more time doing homework because they were distracted, they are currently performing at grade level, however, they at times miss class because of anxiety related to their OCD. They live on campus and share a room with one other person, they are anxious and uncomfortable in crowded settings and when they have to interact with people they are not familiar with.
Mental Status Exam: Pt was seen by the nurse practitioner for their intake appointment via telepsychiatry, they appeared their stated age, they had their preferred pronouns on the display screen, no psychomotor agitation or retardation was noted during the assessment. They had good hygiene and groom, fluent speech, excellent eye contact, they were dressed appropriately of their age, weather and culture, they were calm, cooperative and forthcoming with answers to questions posed by the nurse practitioner. They denied active suicide or homicide ideation and perceptual disturbances, their thought content was devoid of delusions or other thought disorders, their thought process is linear and goal oriented, as evidenced by their desire to seek out professional mental health assistance. Pt endorsed ADHD symptoms, their depressive and OCD symptoms were under control with their current medication regimen, they had good insight and judgment, their recent memory was impaired.
Impression: F33.2 MDD; recurrent Severe without Psychotic Features. F90.0 ADHD; Predominantly Inattentive Type. F42.9 OCD; unspecified.
Discussion and Plan: Wellbutrin XL 150 mg PO QAM was increased to Wellbutrin XL 300 mg PO QAM, Prozac 40 mg PO QAM was decreased to Prozac 20 mg PO QAM; with a plan to taper off within the next two months, Abilify 5 mg PO QHS was refilled without any changes. Pt gave verbal consent after being informed of benefits and possible side effects of treatment, they were encouraged to take their medication daily as prescribed, pt was educated on sleep hygiene measures. Anti-procrastinating techniques were given to the pt, grounding techniques, deep breathing exercises and mindfulness were taught by the nurse practitioner, so that pt may employ when they experience anxiety or depression. They will return for symptom management on 01/30/2023 at 12:15 hours, they were encouraged to reach out with any questions or concerns they may have, prior to their next appointment.
Task
I. Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
II. Objective: What observations did you make during the interview and review of systems?
III. Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
IV. Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.