Sample Type / Medical Specialty: Psychiatry / Psychology

Sample Name: Recheck of ADHD Meds

Description: A 6-year-old male with attention deficit hyperactivity disorder, doing fairly
well with the Adderall.
(Medical Transcription Sample Report)

SUBJECTIVE: This is a 6-year-old male who comes in rechecking his ADHD medicines. We

placed him on Adderall, first time he has been on a stimulant medication last month. Mother
said the next day, he had a wonderful improvement, and he has been doing very well with
the medicine. She has two concerns. It seems like first thing in the morning after he takes
the medicine and it seems like it takes a while for the medicine to kick in. It wears off about
2 and they have problems in the evening with him. He was initially having difficulty with his
appetite but that seems to be coming back but it is more the problems early in the morning
after he takes this medicine than in the afternoon when the thing wears off. His teachers
have seen a dramatic improvement and she did miss a dose this past weekend and said he
was just horrible. The patient even commented that he thought he needed his medication.

PAST HISTORY: Reviewed from appointment on 08/16/2004.

CURRENT MEDICATIONS: He is on Adderall XR 10 mg once daily.

ALLERGIES: To medicines are none.

FAMILY AND SOCIAL HISTORY: Reviewed from appointment on 08/16/2004.

REVIEW OF SYSTEMS: He has been having problems as mentioned in the morning and
later in the afternoon but he has been eating well, sleeping okay. Review of systems is
otherwise negative.

OBJECTIVE: Weight is 46.5 pounds, which is down just a little bit from his appointment last
month. He was 49 pounds, but otherwise, fairly well controlled, not all that active in the
exam room. Physical exam itself was deferred today because he has otherwise been very
healthy.

ASSESSMENT: At this point is attention deficit hyperactivity disorder, doing fairly well with
the Adderall.

PLAN: Discussed with mother two options. Switch him to the Ritalin LA, which I think has
better release of the medicine early in the morning or to increase his Adderall dose. As far
as the afternoon, if she really wanted him to be on the medication, we will do a small dose
of the Adderall, which she would prefer. So I have decided at this point to increase him to
the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon. Mother is to
watch his diet. We would like to recheck his weight if he is doing very well, in two months.
But if there are any problems, especially in the morning then we would do the Ritalin LA.
Mother understa

ample Type / Medical Specialty: Psychiatry / Psychology

Sample Name: Psychiatric Evaluation - 1

Description: Patient with a long history of depression and attention deficits.

(Medical Transcription Sample Report)

IDENTIFYING DATA: The patient is a 36-year-old Caucasian male.

CHIEF COMPLAINT: The patient relates that he originally came to this facility because of
failure to accomplish task, difficulty saying what he wanted to say, and being easily
distracted.

HISTORY OF PRESENT ILLNESS: The patient has been receiving services at this facility
previously, under the care of ABC, M.D., and later XYZ, M.D. Historically, he has found it
very easy to be distracted in the "cubicle" office setting where he sometimes works. He first
remembers having difficulty with concentration in college, but his mother has pointed out to
him that at some point in his early education, one teacher commented that he may have
problems with attention-deficit hyperactivity disorder. Symptoms have included difficulty
sustaining attention (especially in reading), not seeming to listen one spoke into directly,
failure to finish task, difficulty with organization, avoiding task requiring sustained mental
effort, losing things, being distracted by extraneous stimuli, being forgetful. In the past,
probably in high school, the patient recalled being more figidity than now. He tensed to feel
anxious. Sleep has been highly variable. He will go for perhaps months at a time with
middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a
month. Appetite has been good. He has recently gained about 15 pounds, but notes that he
lost about 30 pounds during the time he was taking Adderall. He tends to feel depressed.
His energy level is "better now," but this was very problematic in the past. He has problems
with motivation. In the past, he had passing thoughts of suicide, but this is no longer a
problem.

PSYCHIATRIC HISTORY: The patient has never been hospitalized for psychiatric

purposes. His only treatment has been at this facility. He tried Adderall for a time, and it
helped, but he became hypertensive. Lunesta is effective for his insomnia issues. Effexor
has helped to some degree. He has been prescribed Provigil, as much as 200 mg q.a.m.,
but has been cutting it down to 100 mg q.a.m. with some success. He sometimes takes the
other half of the tablet in the afternoon.

SUBSTANCE ABUSE HISTORY:

Caffeine: Two or three cups of coffee per day, and soda at lunch time.
Tobacco: Denied.
Alcohol: One glass of wine per week. The CAGE screening questions are answered in the
negative.
Illicit drugs: None at present. In high school, he tried marijuana a couple of times, and
cocaine once. We discussed some of the major risk of these substances.
MEDICAL HISTORY AND REVIEW OF SYMPTOMS:
Constitutional: See History of Present Illness. No recent fever or sweats. Neurological: No
history of seizures or migraine headaches. The patient did have a wrestling injury that
resulted in a hole in one retina, but he had no loss of consciousness with that injury.
HEENT: As mentioned above, "hole" in one retina. Cardiovascular: The patient has been
hypertensive in the past with Adderall, and recently he has had some episodes where his
blood pressure was noted to be high, which may be related to his back pain. Pulmonary:
Denied. Gastrointestinal: GERD. The patient has ongoing nausea, which is thought possibly
to be related to adhesions. He has no history of liver disease or peptic ulcer disease.
Endocrine and Hematological: Denied. Dermatological: Eczema as a child. Musculoskeletal:
Chronic back pain from the herniated disc. He was involved in a motor vehicle accident, a
head-on bus crash in the distant past. He is presently awaiting evaluation for possible
surgery. Genitourinary: Denied. Other: Denied.

SURGERIES:
Nissen fundoplication for GERD. Removal of necrotic tissue from his left flank, following an
accidental gunshot wound at age 18; the patient dropped a 44-caliber Ruger, which
discharged.

ALLERGIES:
No known drug allergies.

CURRENT MEDICATIONS:
Prescription: Provigil 100 mg q.a.m. and sometimes 100 mg in the afternoon. The full 200
mg dose caused the patient to "feel wired." Effexor-XR 75 mg q.a.m., Lunesta 2 mg q.h.s.,
generic Vicodin p.r.n back pain.
Over-the-counter: Denied.
Herbal: Denied.

BIRTH AND DEVELOPMENTAL HISTORY:

The patient believes he was probably born fullterm, but is not sure, after a normal
pregnancy. He had a nuchal cord. He weighted about 6-1/2 pounds. He believes he reached
the developmental milestones at the usual ages.

ABUSE HISTORY/TRAUMA/UNUSUAL CHILDHOOD EVENTS:

The patient does not really feel he was abused as a child, but there were some significant
problems when his father returned from his second army tour in Vietnam. He had not met
his father until 2 years of age. He states that his father verbally abused his mother. He can
recall that at about age 3, his father left him on the road, in order to shut him up. His
mother eventually put down her foot, and told his father to quit drinking or they would
separate, and his father chose to give up alcohol. This resulted in much better family
relations.

FAMILY PSYCHIATRIC HISTORY:

The patient's father has suffered from posttraumatic stress disorder, as well as alcoholism.
The patient's mother has had similar symptoms, possibly ADHD, and there is depression on
the mother side of the family. There apparently are a number of family members with
alcohol issues.
FAMILY MEDICAL HISTORY:
The patient's grandfather had a myocardial infarction at age 40, and then died of another MI
in his 50's. The patient's mother had breast cancer. His father had a stroke and
hypertension. His maternal grandmother was obese and had diabetes mellitus. The
maternal grandmother died of colon cancer.

SOCIAL HISTORY:
The patient was born in Grand Junction, Colorado. He came to Alaska in 1977; his father left
his last term of service in the army in Germany at that time, and they came to Alaska to
help a grandparent build a cabin; they ended up staying. The patient has been married for 9
years. He has two daughters, ages 8 and 6.

SPIRITUAL BELIEFS:
He denies any spiritual beliefs.

EDUCATION:
He has a Bachelor of Science degree from the University of Oregon.

EMPLOYMENT:
He is employed at Fort Richardson, through Colorado State University, as a biologist.

LEGAL:
He denies any legal problems.

MENTAL STATUS EXAMINATION:

The patient arrived on time. He is alert, pleasant, and cooperative. He is well groomed and
maintains good eye contact. Intelligence is above average. Insight and judgment are good.
He is oriented to time, place, and person. Memory is good for immediate and recent recall of
three objects. He recalls presidents Bush, Clinton, and Bush. He is able to spell the word
"world" in both forward and reverse directions accurately, but with a bit of difficulty in
reverse. Speech is goal-directed, coherent, and of normal rate and tone. Mood is "good,"
but affect is anxious. The patient becomes more anxious with some of the questioning
during the mental status examination, particularly proverb interpretation. He denies
auditory or visual hallucinations. He denies suicidal or homicidal ideation. He states that the
proverb, "People who live in glass houses shouldn't throw stones" is "speaking about not
being hypocritical."

FORMULATION:
The patient is a 36-year-old Caucasian male with a long history of depression and attention
deficits. Hyperactivity criteria are essentially absent. Although medications have been
somewhat efficacious, he has residual symptoms that are quite troublesome.

DIAGNOSES:
AXIS I 296.32 Major depression, recurrent, moderate.
314.00 Attention-deficit hyperactivity disorder, inattentive type.
AXIS II V71.09 No diagnosis.
AXIS III History of gastroesophageal reflux disease, status post Nissen fundoplication,
variable hypertension of uncertain etiology, retinal damage from the wrestling injury,
chronic back pain.
AXIS IV Occupational problems, other psychosocial and environmental problems.
AXIS V Current GAF: 54. Highest in the past year: 54.

STRENGTHS:
Above average intelligence, college education, stable employment.

PROGNOSIS:
Good, if the patient follows through with appropriate treatment. Without proper treatment,
the patient will likely have further substantial deterioration of psychosocial functioning.

PLAN/RECOMMENDATION:
We have checked the patient's blood pressure today, and it is 140/94. However, he is
experiencing a considerable amount of back pain at this time, which likely contributes to
this. We discussed some of the treatment options, and the patient will return within the next
few days to have his blood pressure checked again. If it remains high, he has been
instructed to see his primary care provider for further treatment. If blood pressure resolves
with better pain control, we will strongly consider increasing Effexor-XR. We discussed in
some detail the risks and benefits of Lunesta, Provigil, and Effexor-XR, and the patient
signed a formal consent form.

Return to clinic in three weeks.

ADHD Consult AND

Exam
CV
PPP
BP
HR
Wt

Patients Goals of Treatment: Managing projects more effectively. Not

feeling behind. Better time management and organization.

ROS
Sleep ok
No chest, palp, No SOB,no claudication, no mania, no depression
Positional hypotension, mild presyncope upon standing 2 times per week. 1
episode syncope many years ago

O/E
HR 60 bpm 105/ 70 mm hg,
CV Normal s1 s2 no murmur, regular rate and rythym, PPPB, no temporal,
aortic or renal bruit. AA non palpable
Abdo soft non nontender
Resp: EAB
wt:76.7 kg

ASSESSMENT
Dx ADHD as per psychiatrist assessment
Low risk for side effects no contraindications
PLAN
1. Trial of Vyvanse 10 MG
Follow up in 1 month to assess response
2. Discussed
Contraindication for Psychostimulant Medication
MOA-i- no
treatment of CVD- no
Glaucoma- no
Arteriosclerosis-no
hyperthyroidism screen
allergy to medication-no
Mania or psychosis- denies
Moderate to severe hypertension 160/100 or sign of end organ damage- no
Pheochromocytoma- on

3.Discussed Potential drug interactions

antidepressants
antipsychotics
anticonvulsants
Warfarin

4.Advised on potential Adverse effects

Tics, Sleep disturbance, Stomach pain,headache, reduced appetite,
hypertension
5. Signed Medication contract
6. Follow weight on subsequent visit
Contraindication for Psychostimulant Medication
MOA-i
treatment of CVD
Glaucoma
Arteriosclerosis
hyperthyroidism
allergy to medication
Mania or psychosis
Moderate to severe hypertension 160/100 or sign of end organ damage
Pheochromocytoma

Potential drug interactions

antidepressants
antipsychotics
anticonvulsants
Warfarin

resources

http://www.helpforadd.com/2013/june.htm
http://www.helpforadd.com/monitor.pdf
http://adhdinadults.com/category/adhd-treatment/
http://naceonline.com/AdultADHDtoolkit/assessmenttools/wfirs.pdf

https://www.mdcalc.com/adult-self-report-scale-asrs-adhd

https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf
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