Comprehensive Psychiatric Assessment Essay Paper
Comprehensive Psychiatric Assessment
Patient Information: K.L. 8 Y/O female
CC: “My daughter has been fidgety and he gets exhausted very easily. She also has excessive worry, irritability and poor concentration.”
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HPI:
An 8-year-old girl is brought to the clinic by her mother, who reveals that she has been getting easily agitated and becomes restless more often. She mentions that the kid has trouble concentrating in her pursuits and academics; she gets exhausted quickly and has feelings of anxiety. She claims that the girl has never been diagnosed with depression and has never had stressful experiences in the past. Mother reports that the girl has been getting worried excessively about his studies, about her family members’ safety, especially when they do not arrive early. She further adds that the kid is overly anxious with accidents and being punctual. Kid is not under any sort of medication. Mother reports that for the past eight months, the girl has had these symptoms and that his tutor has talked about the symptoms and even noticed them Comprehensive Psychiatric Assessment Essay Paper.
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Non-HPI Assessment
Medications: no current medications
Allergies: NKA
PMHx: no chronic medical and mental health disorders.
PSHx: no past surgical history
Personal/ Social History: Client is in Grade 3 and lives with her birth parents and siblings. Her mother denies the use of drugs, alcohol and cigarettes. The girl’s leisure activities include cycling and hiking. Her mother is a chef and her father is a police officer.
Immunization History: Patient received the Influenza vaccine last year in November and other vaccinations are up to date.
Family History: parents and siblings have no history of chronic or mental illnesses.
Review of System
General: Denies fever, increase or reduction in energy levels. Has a sudden change in weight, high body temperatures and sweating at night.
Psych: Reports restless and gets exhausted very easily. She also has irritability, poor concentration, and extreme worry about safety of family members, studies, punctuality, and accidents Comprehensive Psychiatric Assessment Essay Paper.
OBJECTIVE ASSESSMENT
Physical exam: Vital signs; BP 112/73, HR 72, RR 22, Temp 98.1. Wt: 55 lbs; Ht: 4’1; BMI 15.0
GENERAL: Client looks fatigued and tries to be organized with her toys. She also keeps looking at her mother as she plays.
Skin: No rashes, itches, or hives
HEENT: PERRLA, normal or nasopharynx. Extraocular movements intact
Neck: no pain
CV: S1 and S2 are with regular rate and rhythm. Pulse is 3+ throughout and capillaries refill in 2 seconds
Lungs: no wheezing or rales
Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly
Neuro: CN II-XII completely intact.
Musculoskeletal: No kyphosis, positive for muscle weakness
Psychiatric: client appears restless and drained. Her focus is abnormal and she easily gets upset and is unnecessarily anxious about the safety of her family members, and horrific experiences such as accidents Comprehensive Psychiatric Assessment Essay Paper.
ASSESSMENT:
Lab Tests and Results:
Clinical diagnosis: Client meets clinical criteria for GAD as she presents with at least three of the possible six necessary to make a diagnosis.
Thyroid function tests: Normal thyroxine and thyroid-stimulating hormone.
ECG: Normal sinus rhythm
Diagnosis based on DSM 5 and Treatment Plan
Generalized Anxiety Disorder (GAD)
GAD is a condition that is associated with worry that is hard to manage and that significantly interferes with everyday operations. The condition is present in children through exhaustion, irritability, sleeping issues, shaking, nervousness, sweating, nausea, intense worrying about academic achievement, family members’ wellbeing, punctuality, and tragic occurrences such as accidents (Cho, Przeworski & Newman, 2019). The client had several of the symptoms that his mother claimed had been consistent for the last eight months. The client also met all the clinical criteria for GAD because she has at least three of the six potential diagnosis requirements. Other laboratory tests also established generalized anxiety disorder as a primary diagnosis.
Cognitive behavioral therapy and non-drug therapies like anxiety management training, and psycho-education is the appropriate first-line treatment for this client ((Bandelow, Michaelis, & Wedekind, 2017). These treatments are offered prior to the use of medications for mild to moderate cases. The patient’s mother will establish relaxation strategies; sleep routine, workouts and meditation training to be administered on the child (Coplan et al., 2018) Comprehensive Psychiatric Assessment Essay Paper.
References
Bandelow, B., Michaelis, S., & Wedekind, D.3 (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93.
Cho, S., Przeworski, A., & Newman, M. G. (2019). Pediatric generalized anxiety disorder. In Pediatric Anxiety Disorders (pp. 251-275). Academic Press.
Coplan, R. J., Schneider, B. H., Ooi, L. L., & Hipson, W. E. (2018). Peer-based interventions for behaviorally inhibited, socially withdrawn, and socially anxious children.
Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian journal of psychiatry, 61(Suppl 2), 158 Comprehensive Psychiatric Assessment Essay Paper
Patient Information: M.N. 13 Y/O female
CC: “I lack concentration and I can’t pay attention for a period of time. Also, I easily forget.”
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HPI:
M.N. is a 13-year-old female. Presently, she is in the 7th grade and lives with her parents and her sister in a rental home. Lately, her teacher notices she quickly loses concentration and easily forgets things, thereby requesting her mother to take her to a psychiatric evaluation. Additionally, the patient is suffering from careless mistakes and forgetfulness (Danielson et al. 2018). She reports that she has been having mood swings, frustrations, and irritability for almost a year. M.N. seems to be attracted to drawing and swimming as a form of relaxation. Since she started school, she has been suffering from lack of cooperation, forgetfulness, and disorganized. M.N.’s mother reports that her child finds it difficult to make new friends, has difficulty sleeping, and get anxious quickly. The psychiatric assessment shows she suffers from lack of focus and concentration, she fidgets, makes unnecessary movements, and unable to keep calm while interacting with a psychiatrist (Srinath et al., 2019). She is dressed appropriately for the weather, time conservative and shows good hygiene. The patients record an average cognitive ability score on psychoeducational testing.
Non-HPI Assessment
Medications: not on any medication at this time
Allergies: NKA
PMHx: no chronic medical and mental health disorders.
PSHx: no past surgical history
Personal/ Social History: denies drugs abuse. Patient lives under care of both parents and her sister. Spends leisure swimming and drawing. Father is a police officer and her mother work a paralegal.
Immunization History: presently up to date.
Family History: Her mother is 40 years old. She has history of anxiety disorder though she has not seen her psychiatrist in a while. Her grandmother died at 67 years old and was diagnosed with ADHD at 30.
Review of System
General: negative for headache and positive for weight change
Psych: positive for poor attention and difficulty maintaining focus, anxiety and difficulty sleep.
OBJECTIVE ASSESSMENT
Physical exam: Vital signs; BP 110/70, HR 72, RR16. Temp 97.8. Wt: 98 lbs; Ht: 5’2; BMI 17.9.
GENERAL: Well developed; well nourished, not alert; oriented to time, place and person.
Skin: Warm, dry, no rashes
HEENT: PERRLA, normal or nasopharynx, EOMI
Neck: no pain
CV: and S2 present, RRR, S1
Lungs: no rales, no wheezing
Abdomen: Soft, nondistended, nontender, no hepatosplenomegaly
Neuro: CN II-XII completely intact.
Musculoskeletal: No kyphosis, muscle strengths 5/5 all sets.
Psychiatric: Hyperactive
ASSESSMENT:
Lab Tests and Results:
Psychoeducational testing
Evaluated the hidden processes that alters educational achievement and life management capabilities (Svindseth, & Crawford, 2019)Comprehensive Psychiatric Assessment Essay Paper.
Diagnostics
M.N. scored average on educational achievement
Diagnosis based on DSM 5 and Treatment Plan
ADHD
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Attention deficit hyperactivity disorder (ADHD) is a condition that causes abnormal levels of impulses and nervous reaction behaviors. ADHD symptoms include impulsivity and inattentiveness. These affect a patient’s normal academic and social life. This condition should have onset before 13 years and could have been noted either in school or at home. Subsequently, no doubt, the condition reveals the symptoms alter the patient’s academic and social activities. Finally, the revealed symptoms should not be influenced by any unnoticed condition such as schizophrenia disorder. M.N. meets the above DSM-5 criteria, thus she is suffering from ADHD (Mullen, 2018). The differential condition for this condition includes hyperthyroidism, anxiety, and mood disorder.
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The treatment plan for her condition will include the use of psychotherapeutic techniques such as behavioral changes therapy. These treatments will require her to attend weekly counselling individual, group and family sessions. Her teacher will develop an appropriate educational plan that will reduce the patient chances of getting distracted. Her parents will be taught social support through family therapy. References
Danielson, M. L., Bitsko, R. H., Ghandour, R. M., Holbrook, J. R., Kogan, M. D., & Blumberg, S. J. (2018). Prevalence of parent-reported ADHD diagnosis and associated treatment among US children and adolescents, 2016. Journal of Clinical Child & Adolescent Psychology, 47(2), 199-212.
Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275-283.
Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical practice guidelines for assessment of children and adolescents. Indian journal of psychiatry, 61(Suppl 2), 158.
Svindseth, M. F., & Crawford, P. (2019). Humiliation: Mental Health and Public Shame. Emerald Group Publishing Comprehensive Psychiatric Assessment Essay Paper
Comprehensive pediatric (child 5-18 yrs old) psychiatric assessment #3 History of Present Illness Non-HPI Assessment Objective Assessment Diagnosis based on DSM-5 & Treatment Plan Formulation: Neurobiology & Clinical Decision Making Template: Identifying information: patient\’s initial, age, race, etc. Chief complaint: reason for visit History of present illness: Past psychiatric history: Past psychiatric medications: DEVELOPMENTAL HISTORY: Pregnancy complications (include maternal substance use): pregnancy and birth. substance abuse Delivery complications: NICU stay or illness in 1st year: Delays associated with developmental milestones (crawling, walking, toileting, etc.): Any other pertinent developmental history: Family psychiatric history: Substance use history: Past medical history: Allergies: Past surgical history: Developmental and Social history: Review of Systems (ROS) General: Cardiovascular: Respiratory: GI: Neuro: Physical Exam completed: Height: inches Weight: Blood Pressure: Heart Rate: Respirations: Cranial nerves II-XII Mental Status Exam: Motor activity: Speech: Mood: Affect: Thought content: Thought process: Cognition: Recent memory: Insight and judgement: Attention: Diagnostic Impression: Differential Diagnosis: Plan: