Chief complaint: “I am experiencing depression and have lost interest in all activities.”
HPI: The patient is a 31-year-old female with a medical history of depression and breast cancer. She was diagnosed with breast cancer approximately one year ago and has been undergoing chemotherapy. The patient reports feelings of depression and has fears of dying from cancer, likely influenced by her mother’s previous experience with cancer. The patient is currently using Trazodone 50 mg on an as-needed basis for sleep.
Mental Status Examination: The patient displays disorientation, agitation, and disorganization. She appears guarded and exhibits a flat affect. The patient’s appearance is consistent with her stated age, and she appears well-groomed. She denies any current thoughts of suicide. The patient demonstrates limited insight into her own problems.
Diagnosis: The patient is diagnosed with Major Depressive Disorder according to DSM-5 criteria (296.23, F32.2).
Plan: The patient’s treatment plan includes initiating Wellbutrin XL at a daily dosage of 150 mg to address her depression. She will also continue using Trazodone 50 mg as needed for sleep. The patient is referred for psychotherapy to address her emotional well-being. She is educated about the potential side effects of the prescribed medication, emphasizing the importance of medication compliance and adherence to the treatment plan. The patient expresses receptiveness to the provided information and demonstrates readiness to comply with the proposed treatment plan. A follow-up appointment is scheduled in two weeks to evaluate the progress of the treatment.
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6645: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
PRAC 6645 Comprehensive Psychiatric Evaluation Template
Week 7: Case Presentation
Patient Demographic Information
Initials: JJ
Gender: Male
Age: 17-year-old
Race: White
Subjective:
CC (chief complaint): ” I just can’t seem to stay still and focus.”
HPI:
JJ is a 17-year-old white male who presents for an initial mental health evaluation due to a
referral from his primary care physician related to complain of increased aggression, inattention,
forgetfulness, inability to still and obey rules at school. The patient’s mother was present during
the assessment. The patient reports a history of ADHD, conduct disorder, and oppositional
defiant disorder. JJ stated that he was diagnosed with ADT-D at age 7. He was diagnosed with
conduct and oppositional defiant disorder at age 16. He reported a short attention span and is
easily distracted. He stated that he has anxiety and depressive mood sometimes. He reports that
he is always forgetting to do his schoolwork. He stated, ” I am always forgetting and losing
things. I don’t have friends because my mood is easily aggressive and irritable, and I go off on
people” The patient was noted talking excessively, with excessive physical movement. He
reported that he was seeing an outpatient mental health provider and a therapist but stopped six
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
months ago. He also reported taking clonidine 1 mg daily and sertraline 25 mg QPM but
stopped six months because they were not effective. The mother stated that the patient is
currently on suspension from school because he was involved in a fight that injured a classmate.
She also reports that the patient does not listen and refuses to carry out instructions.
Past Psychiatric History:
•
General Statement: Has a significant past history. JJ stated that he was diagnosed with
ADT-D at age 7. He was diagnosed with conduct and oppositional defiant disorder at age
16.
•
Caregivers (if applicable): Has a primary care physician
•
Hospitalizations: None
•
Medication trials: Clonidine 1 mg daily and Sertraline 25 mg QPM.
•
Psychotherapy or Previous Psychiatric Diagnosis: ADHD, Conduct and Oppositional
defiant disorder.
Substance Current Use and History: Denied past or current substance use
Family Psychiatric/Substance Use History: Father has ADHD and is currently in prison for
illicit drug trafficking.
Psychosocial History: The patient currently lives with his mother and sibling. He is the last
child of two siblings and is in 1 Ith grade in high school. The patient does not have a history of
trauma, like sexual, mental, or physical abuse. He does not have any legal issues but gets into
trouble often at school. The patient is currently on three days suspension from school.
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
Medical History: No chronic care medical history
•
Current Medications: The patient is not currently taken any medications
•
Allergies: No known allergies
•
Reproductive Hx: He is single. Does not have children. He is not currently sexually
active.
Objective:
Vital signs: BP 119/66, P-80, R-18, Temp-97.7, Oxygen-98%, Height 5’9, Weight
152, Blood sugar-88mg/dl
Diagnostic results:
•
Magnetic Resonance Imaging (MRI): To validate if abnormal brain structures are causing
the increase in symptoms. The result was normal.
•
Thyroid Stimulating Hormone (TSH): To know the level of the T3 and T4 which might
be causing some of the symptoms to increase. The result was normal.
•
Complete Blood Count (CBC); To monitor the patient general health and wide ranges of
disorders such as anemia, leukemia, and infection. These disorders might be causing
symptoms like inability to concentrate or focus and depressive mood. The result was
normal.
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
•
Liver Functioning Test (LFT); To find out if there is any problem with the liver that
might be increasing symptoms like focusing, irritability, and agitation. The result was
normal.
•
CT Scan- To know if there are changes in the brain activities and to rule out other
neurological disorder. The result was found okay.
•
Urine toxicology test/blood test-These two tests verifies recent use of substance drugs
and amount of alcohol in the blood. The results for both tests were normal.
•
Vitamin B 12: To confirm if there is deficiency of Vitamin B 12 that might be causing
memory problems. The result was okay.
Assessment:
Mental Status Examination:
The patient is alert and oriented to names, places, and things. The patient dressed well for the
assessment and the weather. JJ ambulated by himself with a steady gait. He looked his stated
age. He sits upright in the examination chair and maintained good eye contact in some part of
the assessment. The patient is well-groomed and has good dental hygiene. He seemed forgetful
sometimes during the assessment. JJ talked excessively and displayed increased physical
movement during the assessment. He was cooperative, communicated well, and was able to
express his feelings. The patient’s speech was okay in rate, volume, and tone, but his fluency
was excessive. His thought processes are goal-oriented, organized, and logical. The patient’s
insight and judgment are fair. He denied suicidal and homicidal thoughts. The patient denied
auditory and visual hallucinations at this assessment.
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
Differential Diagnoses:
Conduct Disorder 312.81(F91.1)
Conduct disorder is a cluster of mental health issues in which individuals’ disregards
others feeling. It is characterized by difficulty obeying rules, hostile behavior, and aggressive
and physically violent attitudes (Tonyali et al., 2019). In conduct disorder, physically aggressive
and difficulty in relationships with peers usually starts in childhood before age ten and
progresses into adolescence. According to American Psychiatric Association (2022), conduct
disorder prevalence is about 2 to 10%, with a median of 4%. It occurs more in boys than girls
(American Psychiatric Association, 2022). Social factors such as peer pressure, poverty, stress,
risk-taking activities, depression, and substance use can lead to conduct disorders (Tonyali et al.,
2019). The symptoms of conduct disorder must occur for at least six months before a diagnosis.
Conduct disorder was chosen as the primary diagnostic impression because the symptoms seen
in this patient and it align with the DSM-5-TR criteria. These symptoms include fighting,
physically injuring a fellow student, and aggressive behavior. The diagnostic test used for
conduct disorder includes a blood test to rule out a medical condition that might be causing
symptoms and a urine test to verify if there are any recent illicit drugs and alcohol use.
Oppositional Defiant Disorder (ODD) 313.81 (F91.3)
Oppositional Defiant Disorder (ODD) is a psychiatric condition with a frequent pattern
of disobedient and defiant behavior toward rules. It is characterized by unruly, argumentative,
and a violation of the right of others. The oppositional defiant disorder is diagnosed in children
and teenagers and is caused by genetic and environmental factors (Gomez et al., 2022). ODD
symptoms include aggressive, angry, uncooperative, defiant, and hostile behavior. Other
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
symptoms are disobedience, irritability, blaming, annoying others, and vindictiveness (Gomez et
al., 2022). Diagnoses of ODD are made if the DSM-IV/DSM-IV-TR persists for six months
with at least eight symptoms (Gomez et al., 2022).
A diagnostic test for a child with ODD is Child and Adolescent Disruptive Behavior
Inventory (CADBI). The child and adolescent disruptive behavior inventory is a five scales test
that helps to obtain the clinical nature of the problem. It also assists in knowing the extent of
impairment in the child’s daily functioning caused by the symptoms. (Sheraz & Najan, 2017).
Other tests include a complete blood count, Vitamin B 12 deficiency test, urine toxicology, and
blood test. These tests confirm infection, blood level, and substances use that might be causing
the symptoms experienced by the patient (American Psychiatric Association, 2022). This
diagnostic impression was chosen because it meets the DSM-5 criteria and symptoms displayed
by the patient. These symptoms include aggression, irritability, anger, and inability to follow
and obey instructions. The patient also has depression, anxiety, and hurtful behavior toward
others. This was evidence by his involvement in a fight and injuring a fellow student.
Attention Deficit Hyperactive Disorder (ADHD) 314.01 (F90.1)
Attention deficit hyperactivity disorder is one of the most well-known neurological
disorders that starts in childhood and can last into adulthood (Meyer et al., 2022). The
symptoms in individuals with ADHD include hyperactivity, impulsiveness, inattention,
disorganization, and functional impairment. This functional impairment affects social
relationships, school, and home domains. It is more common in boys than girls (Meyers et al.,
2022). ADHD diagnoses are made in ages 17 years and above with five symptoms within a sixmonth period (American Psychiatric Association, 2022).
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
Attention Deficit Hyperactivity Disorder (ADHD) was chosen as the secondary diagnosis
for this patient because it aligns with DSM-5-TR diagnostic criteria and is supported by
symptoms presented by the patient. These symptoms include impulsivity, difficulty focusing, and
unable to form a social relationship due to his mood. Another symptom displayed by this patient
is excessive talking and increased physical movements. The ADHD self-report scale for
adolescents (ASRS-A) is used to determine the levels of ADHD symptoms clinically with a
score of 9 or higher (Meyers et al., 2022). Diagnostic tests for ADHD include N,’IRI and CT
scans to rule out brain impairment that may be causing symptoms. A complete Blood Count
(CBC) to rule out infection and a TSH test to check for abnormal T3 and T4 that might be
causing symptoms were also done.
Reflections:
I completely agree with my preceptor on the primary diagnosis of Attention deficit
hyperactive disorder chosen for this patient. This is accurate and is due to the symptoms
presented by the patient. The symptoms include inattention, forgetfulness, hyperactivity,
aggression, and irritability. However, some of these symptoms might also be associated with
other psychiatric illnesses like conduct disorder and oppositional defiant disorder. Psychiatric
providers must educate patients and their families about seeking immediate medical care if there
is any concern. If I could conduct the session again, some things I would do differently include
educating the patient and his family on the importance of medication compliance and asking
about the side effects of the medications prescribed. Also, the patient will be encouraged to
partake in a psychological health assessment questionnaire. This assessment will allow more
questions about the patient feelings, thoughts, and behaviors (American Psychiatric Association,
2022). In addition, I will verify the outcomes of other interventions suggested.
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
The interventions were successful because the patient confirmed no side effects of
medications. He was compliant with the pharmacological, non-pharmacological, and alternative
therapy intervention resulting in an improvement of symptoms. I am not able to conduct a
follow-up, I will call the patient and enquire about feelings, moods, side effects of medication,
and medication compliance. I will answer and ask questions that help to improve the patient’s
symptoms. I will also set up a psychiatric follow-up appointment that will be suitable for the
patient.
The social determinant of health is constrained in the environment where people live. The
social determinant of health plays a role in a patient’s health and general well-being (Pronk et
al., 2020). Genetic and single-parent status is a social determinant of health impacting this
patient’s mental health status. The father has a history of ADHD and is presently in prison for
drug trafficking. The mother is a single parent and sole caregiver for this patient and his older
sibling. The patient and his mother will be provided with the available resources and support
groups for assistance with the patient’s condition.
One health promotion activity that needs prompt attention is the creation of a
supportive environment for this patient. Also, the patient will be encouraged to live a healthy
lifestyle and develop healthy eating habits. The patient and his mother will be educated on the
benefits and side effects of the medication ordered. These include nausea, vomiting, loss of
appetite, gas, and constipation. The patient and his mother will be educated on the advantages of
medication adherence. The benefits of keeping a healthy lifestyle will be communicated. The
effects of alcohol and substance abuse will be made known to the patient and his mother. The
patient’s questions and concerns will be addressed appropriately.
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
Case Formulation and Treatment Plan:
After evaluating this patient and hearing and seeing the symptoms he presented, it is
crucial to initiate pharmacologic and nonpharmacologic treatments. The patient will also benefit
from psychotherapy and alternative therapy. These treatments pattern will help to prevent
worsening psychotic symptoms. Cognitive Behavioral Therapy (CBT) is one of the best
therapies needed by this patient due to non-compliance with his medication regime. CBT teaches
individuals how to regulate emotions that are altering behaviors and causing distorted thoughts
(Sadock et al., 2015). CBT treatment for children and adolescents also helps improve social
relationships, interpersonal skills, and general well-being (American Psychiatric Association,
2022).
Parent training in behavioral management is a nonpharmacologic strategy that helps
children suffering from ADHD and conduct disorder. It endows parents with the skills needed to
be self-sufficient to provide support to their children and manage family issues (Shrestha et al.,
2020). Behavioral classroom intervention is another nonpharmacologic treatment for children
diagnosed with ADHD and conduct diso. This technique provides children with ADHD and
conduct disorder special education services in school. This special education includes a reduction
in the amount of homework without decreasing content, providing a quiet environment to study,
and providing clear directions for assignments (Shrestha et al., 2020). Also mind-body
intervention like meditation. Examples of meditation include mindfulness meditation, yoga, and
vipassana. These alternative therapies help patients to build control of their physical and mental
activities (Shrestha et al.,
2020).
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
The patient will be scheduled for a psychiatric follow-up visit in four weeks. During the
follow-up visit, the patient’s progress will be check. The visit will allow the mental health
provider to evaluate any side effects of medications. The patient’s questions and any other
concerns were also be addressed. Adjustments or discontinuation of medication will be
performed if needed. The patient will be instructed to call 911 or go to the nearest emergency if
the need arises. The patient’s psychiatric hotline crisis number was also provided.
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PRAC 6645 Comprehensive Psychiatric Evaluation Template
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: ________________________
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References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
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), 1—
27. https://doi.org/l O. 1 186/s12888-022-03892-5
Meyer, J., Alaie, L, Ramklint, M., & Isaksson, J. (2022). Associated predictors of functional
impairment among adolescents with ADHD—a cross-sectional study. Child &
Adolescent Psychiatry & Mental Health, 16(1), 113.
Pronk, N., P., Kleinman, D. V., & Richmond, T. S. (2021). Healthy People 2030: Moving toward
equitable health and well-being in the United Moving toward equitable health and wellbeing in the United States. ECI
33, 100777. https://doi.org/1 0.1
016/j.ecIinm.2021 .100777
Sadock, B. J., Sadock, V. A. , & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (1 Ith ed.). Wolters Kluwe
Sheraz, A. , & Najam, N. (2017). translation and validation of child and adolescent disruptive
behaviour inventory into Urdu language. Pakistan Journal ofPsychological Research:
32(1). 19—33.
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Shrestha M. , Lautenschleger J. , Soares (2020) N. Non-pharmacologic management of attentiondeficit/hyperactivity disorder in children and adolescents: a review. Transl Pediatr.
(Suppl 14-S124). https://doi.org/10.21037/tp.2019.10.
Tonyall, A., Gök, Z. , & Öneri, Ö. S. (2019). Psychosocial interventions in the treatment of child
and adolescent conduct disorder. Current Approaches in Psychiatry / Psikiyatride Guncel
Yaklasimlar, 11(3), 284—303. https://doi.org/10.18863/pgy.425225.
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