Comprehensive Interventional and General Psychiatry Intake

Chief Complaint: "I feel like I'm constantly on edge and can't focus on anything," reports the patient. HPI: The patient, a 15-year-old male, presents with increasing anxiety and difficulty concentrating over the past six months. He reports feeling overwhelmed at school and struggles to complete assignments. His mother notes a decline in his grades and increased irritability at home. The patient denies any recent trauma but mentions feeling pressured by peers. He has no significant medical concerns but reports occasional headaches. Psychiatric Review of Systems: Depressive, Neurovegetative Symptoms: Reports low energy and difficulty sleeping. Manic Symptoms: Denies any manic episodes. Anxiety Symptoms: Experiences frequent worry and restlessness. Trauma Symptoms: Denies any trauma-related symptoms. OCD Spectrum Symptoms: Reports occasional intrusive thoughts but no compulsions. Tics, Tourette's Symptoms: Denies any tics or Tourette's symptoms. Psychotic Symptoms: Denies hallucinations or delusions. Eating Disorder Symptoms: Denies any eating disorder symptoms. Sleep Symptoms: Reports difficulty falling asleep and frequent awakenings. ADHD symptoms: Reports difficulty focusing and staying organized. Autism Spectrum Symptoms: Denies any symptoms suggestive of autism. Learning Differences: Reports challenges with reading comprehension. ODD, Conduct, Antisocial Symptoms: Denies any oppositional or conduct issues. Borderline Personality Traits: Denies any symptoms suggestive of borderline personality disorder. Other Personality Disorder Symptoms: Denies any other personality disorder symptoms. Past Psychiatric History: Previous Psychiatric Diagnoses: Generalized Anxiety Disorder diagnosed at age 14. Previous Psychiatric Medication Trials: Trial of sertraline, discontinued due to side effects. Previous, Current Therapy: Engaged in cognitive-behavioral therapy for the past year. Previous Psychiatric Hospitalizations: None. Higher levels of care: None. Prior TMS, Ketamine, ECT, Spravato: None. Prior Self-harm: None. Prior suicidal ideation, attempts: None. Prior violence towards others: None. Substance use history: Denies any current or prior substance use. Past Medical And Surgical History: History of asthma, well-controlled with inhaler. No surgical history. Social and Family History: The patient is a high school student, currently in the 10th grade. He enjoys playing video games and soccer. Lives with both parents and a younger sister. Family has a dog. Family History: Mother has a history of anxiety. No access to firearms in the home. Current Meds and Allergies: Currently taking albuterol as needed for asthma. No known drug allergies. Mental Status Exam: General Appearance and Behavior: Well groomed and cooperative. Motor abnormalities: No abnormal motor movements. Speech: Normal rate, rhythm and prosody. Eye contact: Good. Affect: Congruent with anxious content. Mood: "Stressed." Thought content: Preoccupied with academic performance. Thought process: Linear and goal directed. Cognition: Grossly intact attention and memory. Orientation: Alert and oriented. SI,HI,Violent ideation: None mentioned. Insight and judgment: Insight and judgment appear fair. Rating Scales, Labs and Studies: PHQ-9 score: 8, indicating mild depression. Clinical Global Impressions: CGI-S (Severity): 4 - Moderately ill. The patient exhibits clear symptoms of anxiety impacting school performance. CGI-I (Improvement): 3 - Minimally improved. Slight reduction in anxiety symptoms since starting therapy. Assessment: 15-year-old male with Generalized Anxiety Disorder, experiencing academic difficulties. Biopsychosocial formulation indicates stress from school and peer pressure. Ongoing therapy with no changes today. Risk Assessment: No current risk to self or others. Protective factors include supportive family and engagement in therapy. No modifiable risk factors identified. Medication and Somatic Interventions: Consideration of starting a low-dose SSRI if symptoms persist. Psychotherapeutic Interventions: Continue cognitive-behavioral therapy focusing on anxiety management and study skills. Plan: Continue current therapy. Monitor academic performance and anxiety symptoms. Discuss potential medication options if no improvement in the next month. Collaboration Plan: Patient is also seeing a school counselor. Mother involved in therapy sessions to support treatment goals. Safety Plan: Patient aware of how to reach me, covering clinician and members of treatment team in case of emergency (cell) and that email is for non-urgent logistical matters only such as scheduling. Also aware that text messages in the middle of the night are unlikely to be heard so if no response to a text and situation is urgent, calling is most reliable way to reach me. Advised to call 911 or go to the nearest emergency room should any acute safety concerns arise while awaiting a call back. Patient is aware of the 988 Crisis Line as well if needing additional support. Time Spent same day on case: ______