Address the following:
- 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?
- Objective: What observations did you make during the interview and review of systems?
- Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
- 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.
This is a case of a 43-year-old, female White who presents to the clinic today to establish care with a psychiatric practitioner.
The patient reports history of anxiety and a recent diagnosis of ADHD. She reports that her anxiety is somewhat controlled with escitalopram 20 mg and buspirone 15mg daily, but she still experiences high levels of anxiety. The patient decided to get an ADHD evaluation after her son was diagnosed with ADHD and she recognized similar symptoms in herself. She reports that she was seeing a Psych NP through Brightside Health and that her anxiety isn’t well managed. She states that she decided to get an ADHD evaluation with a psychologist. She reports that after getting her evaluation done, she spoke to the psych NP through Brightside and was told that they can’t assist her with any stimulant or non-stimulant medications for ADHD. She reports that she is here for the continuation of care.
Niki describes difficulty focusing and completing tasks both at work and home. She reports being easily distracted and struggling to stay on track with her responsibilities. This has led to difficulties meeting deadlines and functioning effectively at work, particularly with administrative tasks. She also experiences challenges with time management, often being late and forgetful.
The patient’s anxiety symptoms are present, but her mood is stable with no major mood swings or irritability. Her energy and appetite are steady, and her relationships with others are not significantly affected, although people may become annoyed with her forgetfulness and tardiness.
She denies auditory/visual hallucination.
She denies feeling of hopelessness/worthlessness.
She denies paranoia.
Patient denies any suicidal or homicidal intent, ideations or plans.
Patient denies any AVH or any other s/s of psychosis.