Comprehensive Psychiatric Evaluation Note and Patient Case Presentation

Subjective:

ID: Name:AB: DOB: 2010: Age: 14

CC (chief complaint): “We are returning for follow-up.”

HPI: A 14-year-old male was brought to the clinic by his mother for follow-up. The client reports complaints of inattentiveness at school and home. He also has difficulty concentrating, completing tasks, and being in one place for sustained periods: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation.

He also keeps forgetting and losing things, including his school items. These behavioral symptoms have been present since 2nd grade. Likewise, they have been affecting his school performance.

Past Psychiatric History:

• General Statement: The patient has had behavioral symptoms since 2nd grade.
• Hospitalizations: The patient has never been hospitalized before.
• Medication trials: None.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has had behavioral symptoms since second grade. He has been utilizing cognitive behavioral therapy, motivational interviewing, and reflective listening to calm his affect.

Substance Current Use and History: Denies alcohol use or tobacco smoking. The patient also denies using illicit substances and narcotics.

Family Psychiatric/Substance Use History: Family history is negative of any psychiatric illness or substance use.

Psychosocial History: The patient lives with his mother. The mother and the father divorced last year, prompting his father to move out. No history of early childhood exposure to violence or physical abuse.

Medical History: The patient has never been diagnosed with any chronic illnesses. He denies any head injuries, previous hospitalization, accidents, or surgeries.

Current Medications: The patient is not on any medications.

Allergies: No known food or drug allergies.

Reproductive Hx: The patient was born at term through vaginal delivery. No history of pre- and post-partum complications. There is also no history of maternal alcohol use during and after pregnancy.

Objective:

The patient is alert. He appeared engaged and could maintain eye contact during the interview. He fidgeted a lot and kept on changing sitting positions. He also seemed to be losing concentration, as he kept on asking the question to be repeated.

Diagnostic results: Thyroid panel revealed TSH levels of 4.10 (Normal 0.51–4.3 µU/mL). This test ruled out thyroid involvement in the child’s manifestations. Hyperthyroidism is a medical condition that can present with hyperactivity episodes, warranting the inclusion of thyroid tests in the diagnostics.

Assessment:

Mental Status Examination: The patient is alert and oriented to the place, time, and event. He responds appropriately to the interview questions asked. No signs of memory loss, as the child can remember events during and within the interview. His judgment is also logical. His thought process and content are goal-directed and logical. His affect and mood are euthymic.

Differential Diagnoses: 

1. Attention-deficit hyperactivity disorder, combined type:

Attention deficit hyperactive disorder (ADHD) is a mental health condition characterized by inattentiveness and hyperactivity. Patients with ADHD often present with complaints of lack of attention, difficulty concentrating, ease of losing things, difficulty completing tasks, and disorganization (Cabral et al., 2020). These symptoms must have been present for at least six months, have an onset of before 12 years, and interfere with the social functioning of the patient (American Psychiatric Association, 2022).

ADHD is categorized into three forms. These are predominantly inattentive type, predominantly hyperactive type, and the combined type. The patient in the case presented had manifestations of inattention and hyperactivity.

These symptoms have been present since his second grade and interfere with his school work. These features are aligned with those described in the DSM-V for diagnosing ADHD in children. This warranted the inclusion of this differential.

2. Oppositional Defiant Disorder (ODD)

Patients with ODD often present with irritable mood, frequent loss of temper, and vindictiveness. The presence of occasional mood irritation warranted the inclusion of this differential (Gomez et al., 2022). However, the patient’s manifestations fail to meet the threshold for diagnosing ODD as defined in the DSM. This makes this diagnosis less probable.

3. Conduct Disorder, Unspecified

The hallmark features of conduct disorders are patterns of aggression and violation of the rights of others (Sagar et al., 2019). The presence of occasional irritability in the presented case warranted the inclusion of this differential. The diagnosis is, however, less probable as there are no signs of the patient violating other people’s rights.

Diagnosis: ADHD of Combined Type

The presence of inattentive and irritability manifestations points towards the diagnosis. Likewise, diagnostic findings ruled out thyroid disease as a possible cause of the patient’s manifestations. This affirms the ADHD diagnosis.

Case Formulation and Treatment Plan: The patient will continue on CBT, motivational interviewing, and reflective listening. These interventions may help him manage his anger issues as well as calm him. The patient will also be started on amphetamine.

Nazarova et al. (2022) note that pharmacotherapy is the mainstay therapeutic modality in ADHD. Stimulant medications, such as amphetamine, maintain effectiveness in alleviating ADHD symptoms. A trial with this medication is thus warranted.

Reflections:

When managing the patient, one thing I would do differently is to employ rating scales such as the Vanderbilt ADHD scale. Diagnostic scales are valuable in identifying ADHD manifestations and can thus aid the diagnosis (Cabral et al., 2020). A social determinant of health applicable to the case is access to healthcare. Ensuring that patients receive high-quality mental healthcare remains an objective of the Healthy People 2030 initiative (Callaghan et al., 2023).

One health promotion activity I would consider as a future advanced provider is organizing a community outreach program for disruptive behaviors and other mental health illnesses. This will enhance communities’ understanding of the illnesses, reducing apparent stigmatization. A patient education activity is implementing an open workshop for patient engagement on mental health illnesses. This will allow me to educate patients on disruptive disorders.

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev). American Psychiatric Association.

Cabral, M. D., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: Diagnostic criteria, Epidemiology, risk factors and evaluation in Youth. Translational Pediatrics, 9(S1). https://doi.org/10.21037/tp.2019.09.08

Callaghan, T., Kassabian, M., Johnson, N., Shrestha, A., Helduser, J., Horel, S., Bolin, J. N., & Ferdinand, A. O. (2023). Rural healthy people 2030: New Decade, new challenges. Preventive Medicine Reports, 33, 102176. https://doi.org/10.1016/j.pmedr.2023.102176

Gomez, R., Stavropoulos, V., Gomez, A., Brown, T., & Watson, S. (2022). Network analyses of oppositional defiant disorder (ODD) symptoms in children. BMC Psychiatry, 22(1). https://doi.org/10.1186/s12888-022-03892-5

Nazarova, V. A., Sokolov, A. V., Chubarev, V. N., Tarasov, V. V., & Schiöth, H. B. (2022). Treatment of ADHD: Drugs, psychological therapies, devices, complementary and alternative methods as well as the trends in clinical trials. Frontiers in Pharmacology, 13. https://doi.org/10.3389/fphar.2022.1066988

Sagar, R., Patra, B., & Patil, V. (2019). Clinical practice guidelines for the management of conduct disorder. Indian Journal of Psychiatry, 61(8), 270. https://doi.org/10.4103/psychiatry.indianjpsychiatry_539_18

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare

• Review this week’s Learning Resources and consider the insights they provide about impulse-control and conduct disorders.
• Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorderduring the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
• Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy.
• Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Include at least five scholarly resources to support your assessment and diagnostic reasoning.
• Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment
Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

• Dress professionally and present yourself in a professional manner.
• Display your photo ID at the start of the video when you introduce yourself.
• Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
• Present the full complex case study. Be succinct in your presentation, and do not exceed 8 minutes. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
• Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
• 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.

submission information – Part 1: Recording
To submit your video response entry:

• Click on Start Assignment near the top of the page.
• Next, click Text Entry and then click the Embed Kaltura Media button.
• Select your recorded video under My Media.
• Check the box for the End-User License Agreement and select Submit Assignment for review.

submission information – Part 2: Comprehensive Psychiatric Evaluation Note
To submit Part 2 of this Assignment, click on the following link:

• Week 7 Assignment 2, Part 2

Resources:

• DSM-5-TR  text
• Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). WoltersKluwer.
• Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.