Psychiatric Intake - Pediatric NF

Subjective:
Chief Complaint:
Morgan is experiencing social anxiety and depression, characterized by difficulties in social interactions and a persistently low mood.

History of Present Illness:
Morgan's symptoms have been occurring intermittently, with episodes frequently lasting several hours. Over time, these symptoms have remained stable. Various factors modify the symptoms, with structured routines providing relief and unexpected changes causing exacerbation. Associated symptoms include changes in appetite, sleep disturbances, irritability, and trouble concentrating. These issues have significantly impacted Morgan's daily life, affecting school performance, extracurricular activities, and social interactions, and have led to some behavioral issues. Previous evaluations or treatments include psychoeducational assessments and ongoing psychotherapy.

Current Medications:
Morgan is currently taking venlafaxine for their condition and reports no use of over-the-counter supplements.

Allergies:
Morgan reports no notable allergies.

Past Psychiatric History:
Morgan has a psychiatric history of social anxiety disorder and depression. They have been prescribed medications such as venlafaxine, aripiprazole, and lamotrigine, and have participated in psychotherapy. There have been no psychiatric hospitalizations or history of suicidal ideations or attempts.

Substance Use History:
Morgan occasionally uses alcohol, with no mention of tobacco use. Caffeine use is not mentioned. Morgan uses cannabis daily, approximately one gram.

Past Medical History:
Morgan reports no significant medical conditions. There have been no significant hospitalizations or surgeries, and Morgan's immunizations are up-to-date.

Immunizations:
Immunizations are up-to-date.

Family History:
There is a family history of psychiatric disorders, including anxiety and depression. No other medical conditions are reported within the family.

Social History:
Morgan resides in xxx, Ontario, with their parents. School performance issues include difficulty concentrating and social anxiety. Behavioral considerations include rigidity in routines and difficulty with transitions. Screen time and physical activity are not mentioned. Parental concerns include anxiety, depression, and social interaction difficulties.

Personal/Developmental History:
Morgan's immediate family includes their mother and father, with good relationships reported. Morgan was born in xxx, Ontario, from a desired pregnancy, with normal maternal and fetal health. No maternal substance use or complications during pregnancy or delivery were noted. Developmental milestones were reached on time, with no significant temperament or parental emotional state or bonding issues. Morgan is currently in their second year at Northlake University, with normal school experiences and no significant academic struggles. They participate in extracurricular activities such as feminist and gender studies. Friendships and romantic relationships are normal, with no significant conflicts or bullying. Morgan's personality is described as introverted, with mood swings and attention issues noted.

Forensic History:
Any legal issues, including history of arrests or legal battles, are noted if relevant.

The Review of Systems:
Morgan reports general symptoms like fatigue, with psychiatric concerns of anxiety and depression. Other systems are not mentioned.

Objective:
Vital Signs:
Vital signs recorded during the examination include height, weight, BMI, temperature, pulse, blood pressure, respiratory rate, and oxygen saturation.

Mental Status Examination:
The patient appeared cooperative, with normal speech, an anxious mood, and congruent affect. Thought processes were linear, with no delusions or obsessions. There were no hallucinations, insight was good, and judgment was fair. Morgan was oriented to time, place, and person.

Physical Examination:
The general appearance was not assessed. HEENT examination showed no specific findings, with normal pupils, sclerae, and hearing. Respiratory and cardiovascular assessments revealed no abnormalities. The abdomen showed no significant findings. Musculoskeletal and neurological evaluations were normal, and the skin was free of rashes or lesions.

Test Results:
Laboratory tests, imaging studies, or psychological testing results are documented if relevant, providing insight into Morgan's health status.

Assessment:
Differential Diagnosis:
Morgan has been diagnosed with autism spectrum disorder level one (299.00). The assessment suggests a differential diagnosis including social anxiety disorder and attention-deficit/hyperactivity disorder (ADHD).

Problem:
Problems identified include social anxiety (300.23), potential ADHD (314.01), and subtle symptoms of autism spectrum disorder level one.

Impression:
Morgan presents with symptoms consistent with Autism Spectrum Disorder, Level 1 (299.00), characterized by subtle social communication challenges and high functioning. Additionally, Morgan exhibits significant social anxiety (ICD-10: F40.10) and generalized anxiety disorder (ICD-10: F41.1), with a history suggestive of ADHD (ICD-10: F90.9). Depressive symptoms (ICD-10: F32.9) are also noted. Pertinent negatives include the absence of collateral information from teachers, lack of report cards, no ADOS test conducted, and no request for the article mentioned.

Safety Assessment:
Morgan denies any current suicidal or homicidal ideation, intent, or plan. There are no indications of self-harm or risk to others at this time.

Plan:
Morgan and their family were educated on the diagnosis, emphasizing adherence to the treatment regimen and prescribed pharmacotherapy. Coping strategies and lifestyle modifications were discussed to aid management. Guidance was provided on optimizing sleep, maintaining a consistent schedule, encouraging a balanced diet and physical activity, and managing screen time. Referrals for Cognitive-Behavioral Therapy or other relevant psychotherapies were discussed. Medications, dosages, and adverse effect monitoring were included in the treatment plan. Necessary laboratory or imaging tests were ordered to track progress. A follow-up appointment was scheduled to monitor progress and adjust the treatment plan as needed.

Progress and Outcomes:
Morgan, who prefers they/them pronouns, is undergoing an assessment for autism spectrum disorder. It was noted that Morgan does not struggle with following conversational rules, such as storytelling, taking turns, or rephrasing if misunderstood. This is a pertinent negative finding. The clinician has decided not to conduct further autism spectrum disorder assessments for individuals older than 17 years, making Morgan an exception. The importance of sufficient information before making a diagnosis was emphasized, as it significantly impacts the individual's life. The clinician will continue to monitor Morgan's communication skills and other relevant symptoms to ensure an accurate assessment and appropriate support.