PRAC 6645 WEEK 7 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1 Subjective:
CC (chief complaint): “My son has constantly been disobedient.”
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PRAC 6645 WEEK 7 Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1
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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, intentional