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Demographics: 28 year old assigned pt female at birth but uses he/him pronouns, pt is in a relationship with a cis gender male and is a music instructor at a music store.

Chief Concern: “PMDD, ADHD, Gender affirmation”.

History of Present Illness: Pt has been taking antidepressants for depression, anxiety, PMDD and stimulants for ADHD on a consistent basis since 2020, he started HRT; testosterone on 02/14/2022 for gender dysphoria.

Past Medical History: Pt was diagnosed with MDD and ADHD in his teenage years, he had always been uncomfortable with his assigned birth gender, particularly the secondary sex characteristic, this caused him anxiety and depression starting in High School. He also has trouble with focus, attention, is easily distracted, forgets important work deadlines, procrastinates; especially when it comes to work that he perceives as boring.

Medication History:

300mg HCI ER (XL) bupropion- stabilize mood

20mg HCI Fluoxetine – depressive episodes

10mg 24hr ER amphet/dextr – attention deficit disorder

200mg/ml injection Testosterone enanthatate weekly injection – Gender dysphoria

BD Luer-lok syringe 1ml – for testosterone injection

BD Regular Bevel Needles 18 gauge x 1″ needle – testosterone injection

BD safetyglide needles 25 gauge x 5/8″ needle – testosterone injection

Family History: “Parents both bipolar adhd….Dad alcoholic”.

Social History: 28 year year old pt assigned female at birth and is in a long term relationship with a cis gender male, pt uses he/him pronouns, he has been living as a woman most of his life but reports that he started transitioning in 11/2021. He started taking testosterone injections on 02/14/2022, he stated that once he started the testosterone injections, the anxiety regarding gender dysphoria, dissipated. He goes by the name Tyler, pt stated that he does not particularly care if he is misgendered, he has feminine features and stated that sometimes he wears are binder so that his breasts do not show. He is a High School graduate and teaches music at the music store Guitar Center from 15:00-19:00 hours, he is a voice coach, teaches the guitar and ukulele.

Mental Status Exam: Pt was seen at the office by the nurse practitioner for his intake appointment, he rode a motorized scooter to the appointment, he had a steady gait, no psychomotor agitation or retardation was noted. He appeared his stated age, he had good hygiene and grooming, with feminine features, good eye contact, fluent speech, calm and cooperative during the interview. He denied active suicide or homicide ideation and perceptual disturbances, his thought content was devoid of delusions or other thought disorders. Pt reported feeling continuing stress and anxiety about his assigned birth gender. That dysphoria caused intermittent suicide ideations without a plan, he has depressive symptoms; fatigue, not feeling like going to work, anxiety attacks, low self esteem, he started experiencing PMDD at 12 year old, “I`m paranoid and catastrophize when I`m about have my period..”, he reports cramps and mood swings at that time. Pt also has difficulty with sitting still, “I`m always moving around..”, trouble with focus, concentration, he is easily distracted, forgets important work deadlines, procrastinates; especially when it comes to work that he perceives as boring.

Impression: F64.0 Gender Dysphoria, F90.2 ADHD, Combined type, R/O F41.1 GAD

Discussion and Plan: Adderall XR 10 mg PO QAM was prescribed for ADHD, pt was instructed to take the medication daily as prescribed he was informed to watch out mainly for appetite loss, insomnia as side effects, and to only take the medication on days that he works. His concerns and anxieties regarding transitioning were validated. He is not sure about top surgery currently, he will continue receiving HRT, grounding, deep breathing and mindfulness was shared with the pt. He was encouraged to live his authentic life, assertive communication without violating others rights was also encouraged. He will return for supportive therapy, medication and symptom management on 10/03/2022 at 12:00 hours, he was encouraged to reach out with any questions or concerns that he may have, prior to his next appointment.

Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems? 
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis and why? 
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health.  As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
SCIENCE
HEALTH SCIENCE
NURSING
NUR 2307