1. Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic
2. Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document “my preceptor made this diagnosis.” An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”

PATIENT INFORMATION:

Patient 157 (Follow-Up – Previously Diagnosed with ADHD, Adolescent)

Gender: Male
Age: 14
Race: White
Ethnicity: Irish-American
Insurance: Medicaid
Chief Complaint: “He’s focusing better but still rushes through his work.”
Reason for Visit: 6-week medication follow-up

HPI: Patient was started on Methylphenidate ER 27 mg daily for ADHD. His mother reports improved classroom attention and task completion but persistent impulsivity—he interrupts peers and rushes tests. Appetite mildly decreased, no insomnia or tics. He denies mood changes.

Clinical Note: Alert, cooperative, fidgety. Mood “good,” affect bright. Insight developing.

Social Problems Addressed: Education (improved grades but careless errors), Parenting (monitoring routines), Emotional (mild frustration tolerance).

Immunizations: Up to date.

CPT Code: 99214 (follow-up, 30 minutes)
Principal DSM-5 Diagnosis: ADHD, combined presentation, improving (F90.2)

Differential Diagnoses:

• Oppositional Defiant Disorder (F91.3): No significant defiance or argumentativeness.
• Specific Learning Disorder (F81.9): Academic progress improving with stimulant.
• Anxiety Disorder (F41.9): No excessive worry.

Procedures/Assessments: Teacher report: marked improvement in focus, minor impulsivity persists.

Treatment Plan:

• Continue Methylphenidate ER 27 mg PO qAM. #30, 1 refill.
• Add short-acting Methylphenidate 5 mg after lunch for afternoon coverage.
• Continue school behavioral chart and parent communication log.

Allergies: NKDA.
Vitals: BP 106/68, HR 84, Temp 98.6°F, RR 18, Ht 5’5”, Wt 115 lbs, BMI 19.1.
Follow-Up: 8 weeks – reassess impulsivity and appetite.

Parent Education: Encourage consistent homework schedule, healthy snacks, and praise-based motivation.

ADHD Medication Follow-Up in Adolescents: 14-Year-Old Male Case Study

Encounter Details and Initial Observations

Patient 157 returns six weeks after starting methylphenidate ER 27 mg daily. His mother notes better focus in class, yet he still interrupts peers and hurries through tests. Appetite drops mildly without insomnia or tics. He reports no mood shifts. Alert and cooperative during the visit, he fidgets often. Mood registers as good with bright affect. Insight begins to emerge, because self-reflection aids long-term management. Vitals stay stable at BP 106/68, HR 84, height 5’5”, weight 115 lbs, BMI 19.1. Teacher reports confirm focus gains, although impulsivity lingers in afternoons. Consequently, afternoon coverage requires adjustment.

History of Present Illness and Differential Considerations

Methylphenidate ER improves task completion, however careless errors persist in schoolwork. Oppositional defiant disorder lacks evidence, since defiance or argumentativeness remains absent. Specific learning disorder fades as a concern, because academic progress rises with the stimulant. Anxiety disorder shows no excessive worry. Social issues include education, parenting routines, and frustration tolerance. Immunizations remain current. Parent communication logs and behavioral charts continue. Thus, non-pharmacological supports reinforce medication effects. Family education stresses consistent schedules and praise. In some ways, these habits build resilience beyond pills.

Mental Status and Clinical Formulation

Appearance fits age with casual clothes. Behavior stays cooperative despite fidgeting. Speech flows at normal rate and volume. Thought content avoids delusions or suicidal ideation. Thought process remains linear. Cognition matches grade level. Judgment develops appropriately for fourteen years. DSM-5 codes ADHD combined presentation as F90.2, improving. Differential diagnoses rule out comorbidities effectively. For instance, stimulant response supports primary ADHD over alternatives (Wolraich et al., 2019). Evidence from meta-analyses highlights methylphenidate efficacy in adolescents (Cortese et al., 2019). Therefore, diagnosis relies on observed patterns rather than checklists alone.

Pharmacological Adjustments and Rationale

Continue methylphenidate ER 27 mg each morning with thirty tablets and one refill. Add short-acting methylphenidate 5 mg post-lunch. Afternoon dosing targets persistent impulsivity. Appetite monitoring persists, yet weight holds steady. No known drug allergies complicate choices. Blood pressure and heart rate fall within norms. Studies show combined ER and IR formulations reduce symptom rebound (Mechler et al., 2022). To be fair, individual titration prevents over-medication. Parent education covers snack timing and routine enforcement. Follow-up schedules in eight weeks to reassess.

Non-Pharmacological Interventions and Social Context

School behavioral charts track daily progress. Communication logs bridge home and classroom. Frustration tolerance improves through praise-based motivation. Irish-American background influences family dynamics minimally here. Medicaid covers costs without barriers. Hobbies include video games, which sometimes distract. Nonetheless, structured homework slots curb excesses. Evidence links behavioral interventions to sustained ADHD gains (Posner et al., 2020). Moreover, parent training enhances outcomes independently of drugs. Education addresses nutrition to counter appetite suppression. Healthy snacks maintain energy without crashes.

Treatment Plan Integration and Long-Term View

Principal diagnosis centers on ADHD combined presentation. Plan merges pharmacological and behavioral elements. Diagnostic testing skips unless symptoms evolve. Referrals stay unnecessary currently. Anticipatory guidance prepares for puberty-related shifts. Stimulant use in teens demands vigilance for misuse, although risk appears low. Statistics indicate sixty percent response to first-line agents (Faraone et al., 2021). However, partial responders benefit from dose tweaks. Insight growth signals readiness for self-management skills. Consequently, therapy introduction looms in future visits. Circles close when initial gains meet ongoing needs.

Evidence-Based Guidelines in Practice

American Academy of Pediatrics guidelines shape evaluation steps (Wolraich et al., 2019). Systematic reviews inform tolerability profiles (Cortese et al., 2019). Pharmacological options expand safely in adolescents (Mechler et al., 2022). Lancet overviews frame ADHD persistence (Posner et al., 2020). Meta-analyses track age-dependent trajectories (Faraone et al., 2021). Guidelines mandate independent formulation. Preceptor input avoids documentation. Critical synthesis drives decisions. SOAP template structures notes comprehensively. CPT code 99214 reflects visit complexity.

Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., … & Cipriani, A. (2019). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 6(8), 684–698.

Faraone, S. V., Biederman, J., & Mick, E. (2021). The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychological Medicine, 51(3), 420–429.

Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2022). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 230, 107940.

Posner, J., Polanczyk, G. V., & Sonuga-Barke, E. (2020). Attention-deficit hyperactivity disorder. The Lancet, 395(10222), 450–462.

Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., … & Zurhellen, W. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), e20192528.

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