PRAC 6645 WEEK 7 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1
Subjective:
CC (chief complaint): “My son has constantly been disobedient.”
HPI:
W.E. is an 8-year-old Hispanic-American male client who presented for family psychotherapy alongside her mother and her elder brother. The mother reported that her son has been constantly disobedient. W.E. had been referred for psychiatric evaluation by the primary care provider since he exhibited a consistent pattern of rejecting adult authority. He often argued with authority figures, including his teachers, mother, elder brother, and adults. His mother reported that the boy exhibited the behavior since he was six years old, and it worsened when his father separated from his mother. The boy had numerous indiscipline cases in school due to his refusal to comply with school rules and requests from his teachers. He had a tendency to blame his classmates for his mistakes and poor behavior in school. Besides, his classmates avoided interactions since he would get easily annoyed and get them in trouble. The mother had been given a warning letter that if the child’s behavior persisted, he would be expelled from the school.
The patient’s brother reported that he had a tendency to deliberately annoy others, including adults in the neighborhood. He frequently defended him when he got into trouble. The mother reported that he rarely gave attention to the boy’s behavior and often felt the teachers were against the child since they were Hispanics. In recent months, she has tried using harsh punishments such as canning when she has noted the defiant behavior, but they seem ineffective.
Past Psychiatric History:
- General Statement: The patient first presented for psychiatric evaluation because of disruptive behavior.
- Caregivers (if applicable): Mother
- Hospitalizations: None
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: None
Substance Current Use and History: No exposure to alcohol, tobacco, or illicit substances.
Family Psychiatric/Substance Use History: The mother has a history of generalized anxiety disorder and has been on psychotherapy.
Psychosocial History: W.E lives with his mother, brother, and maternal uncle. His parents separated about three years ago, and his mother is the sole provider. The patient has achieved his developmental milestones. He is in 2nd grade but had a poor academic performance. He reports having few friends due to his defiant behavior. He sleeps 8-10 hours a day.
Medical History: The patient has no history of chronic illnesses. He had undergone surgery when he was six months old due to cryptorchidism. His immunizations are up-to-date.
- Current Medications: None
- Allergies: No known allergies
- Reproductive Hx: None
Objective:
Diagnostic results:
HR- 88; RR-20; Temp-98.6
Clinician-Rated Severity of Oppositional Defiant Disorder- Moderate
Assessment:
Mental Status Examination:
The patient is well-groomed and appropriately dressed. He is alert and oriented to person, place, and time. His self-reported mood is ‘good,’ and his affect is congruent. His speech is clear and goal-directed with normal rate and volume. He has a coherent and goal-directed thought process. No delusions, hallucinations, obsessions, compulsions, or phobias were noted. The patient denies having suicidal thoughts or ideations. His short and long-term memory is intact, and he exhibits good judgment.
Differential Diagnoses:
Oppositional Defiant Disorder (ODD): ODD is a type of disruptive behavior disorder that occurs in children. The DSM V defines ODD as a recurrent pattern of irritable or angry mood, argumentative or defiant behavior, or vindictiveness lasting for at least six months. The patient exhibits features of ODD with symptoms from both Angry/irritable mood and Argumentative/Defiant behavior categories (Arias et al., 2021). Positive findings in the patient include being easily annoyed, arguing with authority figures and adults, intentionally annoying others, and blaming other for his mistakes and undesirable behaviors.
Conduct Disorder: The DSM-V diagnostic criteria for Conduct Disorder require the presence of at least three of the following symptoms in the past six months from each category. The first category includes aggression toward people and animals, such as fighting, bullying, threatening, and being physically cruel to individuals or animals. The second category is the destruction of property by fire or other means. The third category is being deceitful (Colins et al., 2021). The last category includes serious violations of rules, such as ignoring parents’ orders and being truant in school. The patient has a history of violating rules at school and ignoring rules from his mother and teachers.
Disruptive Mood Dysregulation Disorder (DMDD): DMDD is a childhood disorder characterized by a constant and severe irritable mood that is out of proportion in intensity and duration alongside frequent temper outbursts (Benarous et al., 2020). Children with DMDD have severe temper outbursts, verbal or behavioral, with an average of three or more temper outbursts per week. The disorder results in severe impairment that necessitates clinical attention (Hendrickson et al., 2020). DMDD is a differential based on the patient’s getting into arguments with authority figures, including his teachers, mother, and elder brother, and with adults.
Reflections: In a similar patient evaluation, I would assess how the patient’s mother’s history of GAD affected her relationship with her son. I would also ask the mother if she has difficulties regulating her emotions when dealing with her son. Structural factors, including education, occupation, and income, are linked with mental health problems in children. Enelamah et al. (2023) explain that children whose parents have a low income and education level are at more risk of developing emotional and behavioral health disorders like ODD. Thus, this could have influenced the development of disruptive behavior in the child. Health promotion should focus on training the child’s parent on measures to change her behaviors and thus alter the boy’s problematic behavior at home.
Case Formulation and Treatment Plan: Oppositional Defiant Disorder
Psychotherapy: The psychotherapy plan will include individual psychotherapy and family intervention involving direct parent training.
Child individual CBT will be used to teach the patient anger management and social- and cognitive problem-solving skills. Training children with ODD on social problem-solving measures enhances their emotion-regulatory skills and leads to decreased irritability (Helander et al., 2023).
Parent Management Training (PMT) was recommended to teach the patient’s mother parenting strategies to help alleviate disruptive behavior (Helander et al., 2023).
Follow-up: A visit was scheduled after four weeks to assess the patient’s progress with psychotherapy.
Referrals: The patient will be referred to a child psychiatrist for medication review if he does not improve with psychotherapy alone.
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
Benarous, X., Bury, V., Lahaye, H., Desrosiers, L., Cohen, D., & Guilé, J. M. (2020). Sensory processing difficulties in youths with disruptive mood dysregulation disorder. Frontiers in Psychiatry, 11, 164. https://doi.org/10.3389/fpsyt.2020.00164
Arias, V. B., Aguayo, V., & Navas, P. (2021). Validity of DSM-5 oppositional defiant disorder symptoms in children with intellectual disability. International Journal of Environmental Research and Public Health, 18(4), 1977. https://doi.org/10.3390/ijerph18041977
Colins, O. F., Fanti, K. A., & Andershed, H. (2021). The DSM-5 limited prosocial emotions specifier for conduct disorder: Comorbid problems, prognosis, and antecedents. Journal of the American Academy of Child & Adolescent Psychiatry, 60(8), 1020–1029. https://doi.org/10.1016/j.jaac.2020.09.022
Enelamah, N. V., Lombe, M., Yu, M., Villodas, M. L., Foell, A., Newransky, C., Smith, L. C., & Nebbitt, V. (2023). Structural and Intermediary Social Determinants of Health and the Emotional and Behavioral Health of US Children. Children (Basel, Switzerland), 10(7), 1100. https://doi.org/10.3390/children10071100
Helander, M., Enebrink, P., Hellner, C., & Ahlen, J. (2023). Parent Management Training Combined with Group-CBT Compared to Parent Management Training Only for Oppositional Defiant Disorder Symptoms: 2-Year Follow-Up of a Randomized Controlled Trial. Child Psychiatry and Human Development, 54(4), 1112–1126. https://doi.org/10.1007/s10578-021-01306-3
Hendrickson, B., Girma, M., & Miller, L. (2020). Review of the clinical approach to the treatment of disruptive mood dysregulation disorder. International Review of Psychiatry (Abingdon, England), 32(3), 202–211. https://doi.org/10.1080/09540261.2019.1688260
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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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
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:
Rubric
PRAC_6645_Week7_Assignment2_PT1_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning Outcome Photo ID display and professional attire |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Time |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Discuss Objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Discuss results of Assessment:• Results of the mental status examination• 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 diagnostic criteria and is supported by the patient’s symptoms. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Discuss treatment Plan:• A treatment plan for the patient that addresses psychotherapy and rationales including a plan for follow-up parameters and referrals |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Presentation style |
|
5 pts | ||||
| Total Points: 75 | ||||||
