15 yr old child with ADHD which was really good. This paper however needs to address adult ADHD. Patient is a 52-year-old male presents to the clinic to establish care. Diagnosis of Adult ADHA/F90.9. Past and current medications: AdderalL 20 mg tablet Take 1 tablet(s) 3 times a day by oral route as directed for 30 days dextroamphetamine-amphetamine 30 mg tablet TAKE 1 TABLET BY MOUTH TWICE A DAY- last filled 10/2020 Family History Reviewed Family History Father – No current problems or disability Mother – No current problems or disability Social History Reviewed Social History Education and Occupation What is the highest grade or level of school you have completed or the highest degree you have received?:
Some college, no degree Are you currently employed?: Yes (Notes: PROPERTY MGT) Diet and Exercise What type of diet are you following?: Regular Activities of Daily Living Are you able to care for yourself?: Yes Are you blind or do you have difficulty seeing?: No Are you deaf or do you have serious difficulty hearing? : No Do you have difficulty concentrating, remembering or making decisions?: Yes Do you have difficulty walking or climbing stairs?: No Do you have difficulty dressing or bathing?: No Do you have difficulty doing errands alone?: No Are you able to walk?: Yes: walks without restrictions Do you have transportation difficulties?: No Marriage and Sexuality What is your relationship status?: Married How many children do you have?: 1 Substance Use Do you or have you ever smoked tobacco?: Current everyday smoker How much tobacco do you smoke?: 1/2 pack per a day Advanced Directive Do you have an advanced directive?: No Home and Environment Have there been any changes to your family or social situation?: No Lifestyle Do you feel stressed (tense, restless, nervous, or anxious, or unable to sleep at night)?:
Not at all Do you participate in social media?: No Reported by a patient. Context: able to set limits with obligations; no dysfunction in family; no financial problems Modifying factors: improves with medication; improves with structured time Evidence of medication: appropriate use Reports compliance with treatment , improved focus , less distracted , eating three meals per day No headaches , no dizziness No palpitations , no chest pain , no edema No N/V/D ROS Patient reports no fever, no recent involuntary weight loss, no recent involuntary weight gain, and no night sweats. He reports no loss of consciousness, no numbness, no weakness, no restless legs, no frequent or severe headaches, and no dizziness. He reports no depression, no sleep problems, and no alcohol cravings/abuse. He reports no hives, no frequent sneezing, and no pruritus.
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