Date of Visit: June 13
Appointment Time: 830 am
Cc: Previous Doctor’s office closed, and it has been hard to
find someone new. Referred by PCP.
No allergies
Initials: D.J.
Job: Construction
Dob: July 5, 1980
Patient had been taking Adderall for 7 years but stopped
taking the medication a year ago. Was looking for a non stimulant option
because he felt short tempered, and experienced mood changes. He also reports depression
past 2 years. Discontinued Adderall because of side effects. Was irritated and
didn’t like when medication left his system.
Completed adhd online a questionnaire but he was already on Adderall
at that time. He reports that it was hard to answer questions since he was
being medicated.
Depressive symptoms for past 2 years, and has tried non-medical
approaches such as Ketamine, and talk therapy. He felt that Ketamine results were
short lived.
Patient was asked why does he want to seek treatment now?
“I need to feel better and I don’t like the way that I feel.”
(chief complaint)
Has cut back alcohol use significantly. Used to drink daily after work.
Suicide thoughts but he has a daughter and wouldn’t leave
her here without a father. As soon as the thought enters then he thinks of his
daughter. He gets tearful that he thinks that way. His daughter is 4 years old.
Taking testosterone but last dose was 6 months. His new pcp
will check his labs
Levothyroxine: 88 mg but need labs checked
Weight 155 lbs
Ht: 5 ft 9 inches
Took Adderall for 7 years and then did a adhd questionnaire
1 year ago with a virtual psychologist so the Psychiatrist could refill
medication
Besides Adderall has he not tried any medications for mood.
Emergency contact is spouse Christy
Ever been admitted to hospital for mood: no
Any trauma? No
Wife 36 years old
Been together since 2013 and married since 2016
Family hx mood issues or psychiatric: mom (anxiety)
Dad unsure because he is in Russia but living but no
relationship
Siblings half sister with no medical issues
Lives with wife, daughter and mom comes to help but
primarily lives in Florida just helping. Russian
Mom: high school, born in 1958
Highschool and some college
Spiritual: Christian non denomination. Not in church that
much
No legal issues
Smoking or vaping: no
Drinks: 1 cup a day of coffee
Alcohol: weekends or dinner now used to be daily 1 to 2
drinks. Weekends: 1 to 2 drinks. Drinks
vodka mixed drink
Vodka cranberry or
red bull
No drug use
History of attempted suicide: no
Any history of aggression: no
Access to weapons, gun. Collects them. Are in a safe
Depression scale: high 20, phq9 scale
Anxiety high: 20 (GAD scale)
Which is more distressing? Depression
Depression is more constant
Anxiety just pops up.
When trouble sleeping he has tried Melatonin but hasn’t
worked. He will try to calm self down, breathing or walking to spending time
with daughter
Exercise: no just daily labor at work
Benadryl in the past for an allergic reaction but doesn’t
remember if he felt sleepy.
Sleep issue happens once a week because of anxiety. He will walk it off or distract self
Bupropion or wellbutrin helps with depression and adhd. Can
help with anxiety related to depressive symptoms?
No sexual side effects it can help with fatigue
Will prescribe: Bupropion 150 mg xr
Take in the morning with food
Recommend checking testerone and thyroid level. Follow up 2
weeks 830 am
43 year old white male
Depressive symptoms and adhd
No ssri because of sexual se and low testosterone
MSE:
Appearance: Patient appears his stated age. Patient is
appropriately dressed and appears to have good hygiene. No visible tattoos
noted. No scars noted.
Affect: Appropriate affect, normal expressions.
Behavior: Patient is cooperative and not in any distress.
Patient’s behavior is appropriate for the clinical encounter. Eye contact
maintained and appropriate.
Motor activity: normal movement and motor activity.
Patient’s posture is appropriate.
Speech: Appropriate speech, no accent, patient is engaged
and responding appropriately. Speech is not rushed or delayed. No slurred
speech.
Mood: Feeling anxious and depressed
Thought: Normal thought process, linear, and goal directed.
Patient has had suicidal thoughts in the past, but denies any intention, or
plan.
Perceptions: Denies auditory or visual hallucinations.
Cognition: Patient is alert, and oriented. Patient’s
attention and concentration is maintained throughout the interview.
Insight: Patient has good insight and able to understand his
diagnosis.
Judgment: Good
