Reference no: EM133933101
Problem
Write a follow up psych progress note on this same patient creating a scenario to add to this previous visit note which result in the increase of her medication Buspirone and prompting a follow up in 2 weeks Maintain this pattern.
CC: follow up for medication management for Anxiety and ADHD management
HPI: Patient is a 19-year-old female presenting with concern about increased anxiety related to returning to school. She reports difficulties in concentrating during classes and a heightened sense of stress when handling assignments, consistent with her ADHD history. She describes episodes of procrastination due to anxiety about her academic performance and experiences racing thoughts, especially at night, which disrupt her sleep. However, she feels motivated to resume studies and improve her academic standing.
PMH: Diagnosed with ADHD at age 13; history of anxiety during previous school transitions. No hospitalizations or significant medical concerns in the past year. Get the instant assignment help.
Exam: Mood: Anxious but determined; affect congruent with induced stress periods. Sleep: Reports trouble falling asleep due to racing thoughts, averaging 5-6 hours per night.
Cognition: Alert and oriented, with occasional difficulties maintaining attention.
Current Medications: Methylphenidate 10 mg twice daily for ADHD management Buspirone 5 mg twice daily for anxiety Melatonin 3 mg nightly for sleep support Assessment: Patient exhibits ongoing symptoms of ADHD alongside anxiety, affecting her academic performance and social interactions. She expresses a commitment to managing these symptoms as she transitions back to school.
Plan: Medication Management: Continue Methylphenidate 10 mg twice daily, monitor for effectiveness and side effects. Continue Buspirone 5 mg twice daily, consider dose adjustment if anxiety persists. Started Melatonin 3 mg nightly to improve sleep patterns and reduce sleep onset latency.
Therapeutic Support: Continue attending individual therapy focusing on cognitive-behavioral strategies to manage anxiety. Explore ADHD coaching techniques to develop structured routines and effective study habits.
Lifestyle Modifications: Encouraged mindfulness practices and stress-reduction techniques such as breathing exercises. Encouraged regular physical exercise, including activities like jogging or dancing, to help manage stress.
Encouraged time management skills and use of planners or digital apps to organize schoolwork. Education: Reviewed strategies for managing ADHD symptoms effectively in the school context. Discussed realistic expectations and gradual exposure to social and academic settings to reduce overwhelm.
Follow-up in 2 weeks to evaluate school transition progress and medication efficacy. Assess for any adverse effects from the current medication regimen and adjust as needed. Notes: Patient is motivated and appreciates the support in managing both ADHD and anxiety. She expresses a desire to develop long-term coping strategies to enhance her academic and social life. Encourage ongoing communication with her academic advisor for additional school-based support.