Case History Reports

A 30-year-old Caucasian female who comes in with difficulties in concentration and focus since she was in college she did ok in high school. Vital: T- 98.3 P- 97 R 22 140/84 Ht 5’8 Wt 160lbs Background: Born and raised in Texas. Loves singing and attending church weekly. Patient states that she gets distracted easily, not completing tasks. Patient was diagnosed with ADHD back in 2016. Patient resisted in the past to take meds. At one point she was given Ritalin 5mg daily. It did not help; she took it very briefly and did not like the idea of taking meds so stopped altogether. She also suffers from anxiety and seeing a psychotherapist off and on since 2015.
Currently seeing therapist also for anxiety which she believes is helping her. She submitted a document showing that in May 2021 while she was in Texas doing her master’s program, she saw a psychologist who did psychological testing and diagnosed her with ADHD and anxiety disorder.
Patient states that she is having a hard time in focus and concentration. Her mind is raising and her mind is all over she is not completing tasks on time. Also, she is not organized in her work habit does not want to lose her job hence decided to be on meds for ADHD, denied depression. Hx of social anxiety but not too bad does not come on her way to interact with people. No hx of mood swings, no mania, no OCD, denied a/h no delusion, no insomnia, appetite good, denied si no hx of EtOH and drug abuse. The patient claims that she was hospitalized last month due to a mental breakdown. Was discharged home with Adderall 10 mg which it helped but now she is out of meds
Education Highest Grade: Graduate/Professional School
Current Occupation: RESEARCH ASSISTANT
Current Relationship Status: SINGLE
PMH: Allergic rhinitis, Migraine
Past Surgeries: Wisdom teeth removed 2013, Appendix: 2019
Pregnancy Status: one abortion 2018
Family History: Father -Anxiety, Depression, High cholesterol, Stroke
Mother -Arthritis, Depression, Stroke
Sister: -Alcoholism, Bipolar disorder, ADHD
Current Medications Reported by Patient: doxycycline 100 mg capsule for the treatment of Acne
Allergies: Bactrim, Dust mites
Social History: Never smoker but drinks about 5 beers weekly
Assignment Instructions:

  1. Review the additional data for the case in the “Case History Reports below” document, keeping the requirements of the evaluation template in mind.
  2. Consider what history would be necessary to collect from this patient.
  3. Consider what interview questions you would need to ask this patient.

Sample Solution