Comprehensive Psychiatric Evaluation

• Due Dec 25 by 10:59pm
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COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 2

BY DAY 7

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Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder

Patient Initials: H.F.

Gender: Male

SUBJECTIVE:

CC: “He has been suspended from school, and I cannot contain him anymore.”

HPI: The patient (H.F), a 16-year-old male, presents at the clinic with his mother, concerned about his increased aggressive behavior and dislike for people, especially schoolmates and older neighbors. The mother reports that H.F. is suspended from school after engaging in pervasive aggressive behavior, bullying, breaking school furniture, drawing on the wall, and picking fights with fellow students and teachers. The mother states that since he turned 15, he has been a different person, does not like to be around people, and locks himself in his room. He is also accused of stealing things in school, and before his suspension, he had carried a knife, which he used to threaten a teacher. The mother reports that she cannot leave her purse or the husband cannot leave his wallet unattended because H.F. has developed a tendency to take money without asking. She also reports that H.F. spent three nights away from home last month without giving notice or asking for permission. Until now, his parents do not know where he was. It also happened once when he was 12, but he was punished and promised not to do it again. The mother fears that he is also engaging in risky sexual behavior, as he has been seen with multiple girls, often older than him, and alcohol and substance use because the mother found a bottle in his room. She reports that he is also aggressive towards their cat and fears he will hurt it.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Social History: H.F. lives with his parents. He has an older brother, who lives away from home, and a younger sister, who is in Grade 6.

Education and Occupation History: H.F. is in high school.

Substance Current Use and History: The reports using alcohol occasionally.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)   

Legal History: The client denies any legal history, but he has been punished multiple times in school and at home.

Family Psychiatric/Substance Use History: The mother denies family mental health. She reports that her husband uses alcohol occasionally.

Past Psychiatric History:

Hospitalization: Denies hospitalization history.

Medication trials: Denies history of medical trials.

Psychotherapy or Previous Psychiatric Diagnosis: Was previously evaluated for ADHD, but a diagnosis was not established.

Medical History: None.   

• Current Medications: Denies using any medications currently.
• Allergies:
• Reproductive Hx: Sexually active. H.F. states using protection.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

ROS:  

General: The patient is well-nourished, normal activity levels. Denies fever or fatigue.  

HEENT: Eyes: Patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: Patient denies diet changes, feelings of nausea and vomiting. Denies diarrhea. No abdominal pain or blood. Denies constipation. History of GERD.  

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color

Neurological: The patient denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Reports concentration and attention problems.

Musculoskeletal: The patient denies muscle pain and weakness. Denies back pain and muscle or joint stiffness. Moves all extremities well.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Psychiatric: History of behavior problems. Recent complaints of ill conduct.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Endocrinologic: Denies sweating. No reports of cold or heat intolerance. No polyuria or polydipsia.

OBJECTIVE:

Vital signs: Stable

Temp: 97.8F

            B.P.: 110/70

            P: 85

             R.R.: 19

             O2: Room air

             Pain: 0/10

             Ht: 5’9 feet

             Wt: 170 lbs

             BMI: 25.1

             BMI Range: Overweight

LABS:

Lab findings WNL

Tox screen: Positive

Alcohol: Positive

Physical Exam:

General appearance: The patient is awake, healthy-appearing, well-developed, and well-nourished.  

HEENT: Normocephalic and atraumatic. Sclera anicteric, No conjunctival erythema, PERRLA, oropharynx red, moist mucous membranes.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Neck: Supple. No JVD. Trachea midline. No pain, swelling, or palpable nodules.

Heart/Peripheral Vascular: Regular rate and rhythm noted. No murmurs. No palpitation. No peripheral edema to palpation bilaterally.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Cardiovascular: The patient’s heartbeat and rhythm are normal. The patient’s heart rate is normal, and capillaries refill within two seconds.

Musculoskeletal: Normal range of motion. Normal motor strength and tone.

Respiratory: No wheezes, and respirations are easy and regular.

Neurological: Balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear. The patient has frequent headaches.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Psychiatric: The patient is easily distracted and is uncooperative in some instances.   

Neuropsychological testing: Social-emotional functioning is impaired.

Behavior/motor activity: The patient was uncooperative in some instances.

Gait/station: Stable.

Mood: Good.

Affect: Good.

Thought process/associations: Comparatively linear and goal-directed.

Thought content: Thought content was appropriate.

Attitude: The patient was uncooperative at times(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Orientation: Oriented to self, place, situation, and general timeframe.

Attention/concentration: Impaired

Insight: Good

Judgment: Good.

Remote memory: Good

Short-term memory: Good

Intellectual /cognitive function: Good

Language: Clear speech, with a tone assessed to be normal

Fund of knowledge: Good.

Suicidal ideation: Negative.

Homicide ideation: Negative.

ASSESSMENT:

Mental Status Examination:

The 16-year-old male patient presents with complaints of ill and ungovernable behavior and conduct from the mother. The patient is uncooperative, aggressive, bullied, and easily agitated. The patient demonstrated impaired concentration and attention, making building rapport challenging. His mood and affect were good, but he had impaired attention and focus, was apathetic, and was easily irritated. He denies any thoughts of suicide or homicide. The mother fears that if the ill behavior and conduct continue, her son will end up in jail.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)   

Differential Diagnosis:

1. 9 Conduct Disorder

Disruptive behavioral disorders include conduct disorder (CD) and oppositional defiant disorder (ODD). In some circumstances, ODD appears before CD. The CD is characterized by a series of behaviors, including showing hostility and violating other people’s rights. Conduct disorder frequently co-occurs with psychiatric diseases such as depression, attention deficit hyperactivity disorder, and learning problems (Mohan et al., 2023). It is vital to remember that occasional rebellious conduct and a propensity to disrespect and disobey authority figures can be seen frequently during childhood and adolescence. The signs and symptoms of CD show a pervasive and recurrent pattern of hostility towards people and animals, as well as the destruction of property and breaking of regulations (Sagar et al., 2019). Per the DMS-5 criteria, an individual must exhibit behaviours that violate other people’s rights and disregard acceptable conduct. The individuals should also demonstrate dysfunction in various areas, including aggression toward other people and animals such as initiating fights, carrying and using weapons, bullying, threatening, and being cruel towards people and animals, deliberate property destruction, stealing and lying, and significant violation of rules like running away from home and staying out late (Zhang et al., 2018). H.F. presents with all these dysfunctions, confirming the diagnosis.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

2. 3 Oppositional Defiant Disorder

Opposition defiant disorder is also a disruptive behavioral disorder that often precedes CD. Due in part to the overlapping normative conflict between children and their parents, ODD is rarely recognized in older children and teenagers. Males are more likely than females to have ODD in preadolescence (1.4:1), but neither adolescents nor adults exhibit this male predominance (Aggarwal & Marwaha, 2022). Symptoms are believed to be generally stable between the ages of five and ten, and after that, they start to decline. It mainly entails issues with the restraint of emotions and actions. According to the DSM-5 criteria, the fundamental characteristic of ODD is a recurring pattern of anger or irritability, argumentative or defiant behavior, or retaliation against others (Aggarwal & Marwaha, 2022). This diagnosis was refuted because the patient presented with ODD and additional symptoms that fit CD criteria. (Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

3. 9 Attention Deficit Hyperactivity Disorder

Attention deficit Disorder often co-occurs with CD and impairs an individual’s ability to function. People with this illness exhibit tendencies of inattentiveness, hyperactivity, or impulsivity at developmentally inappropriate levels. Young children with ADHD typically exhibit inattentiveness, lack of concentration, disorganization, difficulty finishing chores, forgetfulness, and losing items (Magnus et al., 2023). To qualify as having “ADHD,” a person’s symptoms must start before age 12, endure for six months, and interfere with daily activities. It must be present in multiple environments, such as at home, school, or after-school activities (Magnus et al., 2023). Large-scale repercussions may include problematic social interactions, a rise in risky conduct, job losses, and difficulties in the classroom. The diagnosis was refuted because ADHD was not established before age 12, and the student does not present with functioning difficulties but only inattentiveness.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

PLAN:

The patient would benefit from a combination of pharmacotherapy and psychotherapy.

Safety Risk/Plan:

H.F. has no desire to harm himself or others and has no current plans. The patient has no suicidal or homicidal thoughts. Admission is not necessary.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Pharmacological Interventions:

Pharmacotherapy aims to treat mental co-morbidities with the proper medications, such as stimulants and non-stimulants for treating ADHD, antidepressants for addressing depression, and mood stabilizers for treating aggression and mood dysregulation (Mohan et al., 2023). Antiepileptic medications (AEDs) and second-generation antipsychotics are traditional mood stabilizers that can improve mood.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Psychotherapy:

Parent management training, which aims to teach parents how to discipline their children consistently, reward positive behavior appropriately, and encourage prosocial behavior in kids, multisystemic therapy, which targets family, school, and individual issues; and anger management training are all part of the psychosocial treatment that can help address conduct disorder in H.F. Moreover, individual psychotherapy focusing on problem-solving abilities builds connections by resolving interpersonal problems and teaches assertiveness to decline harmful influences in the community, which is useful in treating CD (Mohan et al., 2023). The development of therapeutic school environments that can offer a structured program to lessen disruptive behaviors in the future will be the focus of community-based treatment.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Education:

1. Advise the client of the necessity for drug adherence, possible adverse effects, and potential complications from taking the medication.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)
2. Advise the client that additional therapy sessions are necessary.
3. Monitor withdrawal symptoms frequently to prevent relapse.
4. Inform the client regarding healthy behaviors and attitudes.
5. Encourage the patient to cooperate with the medical staff and seek assistance anytime.
6. Encourage the client to participate in group therapy or a support group to develop social skills.

Consultation/follow-up: Follow-up is in two weeks for further assessment.

Reflection

Dealing with H.F. was challenging because the patient was problematic and uncooperative in some instances, sometimes extending his aggression toward the practitioner, raising the risk of harm. However, the process is more effective when professionals, parents, and teachers work together. If given another opportunity with the client, I would seek information from the teacher and the school’s disciplinary members to develop a more comprehensive evaluation and treatment plan. I would involve parents’ and teachers’ perspectives in developing this patient’s care plan and strategies to ensure quick recovery and sustainability of acceptable conduct.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Healthcare access and quality are social determinants of health, significantly impacting health quality and patient outcomes. Healthy People 2030 seeks to enhance health by helping people receive timely, high-quality healthcare services. In line with mental health and corresponding to this particular case, Healthy People 2030 aims to increase the proportion of children and adolescents with significant emotional and mental health conditions receiving treatment (Healthy People 2030, 2022). This goal is a priority because mental health in children and adolescents is increasingly becoming a serious public health issue. Therefore, increasing treatment availability would help people like H.F. receive the care they need and lead a quality life.  

Regarding health promotion, parent and parent-child sessions focusing on coping skills and parental advice on dealing with CD can help address this problem. This activity will allow the parent and the patient to build a healthy relationship, enhance cooperation, and strengthen parent management skills (Mohan et al., 2023). Moreover, on patient education, family therapy focusing on the need for treatment and professional intervention can help the clients appreciate the treatment and embrace professional advice in line with healthcare access and quality. Improved relationships between family members are needed to promote positive behavior.(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

References

Aggarwal, A., & Marwaha, R. (2022). Oppositional Defiant Disorder. In StatPearls [Internet]. StatPearls Publishing.

Healthy People 2030. (2022). Increase the number of children and adolescents with serious emotional disturbance who get treatment — MHMD‑D01. https://health.gov/healthypeople/objectives-and-data/browse-objectives/mental-health-and-mental-disorders/increase-number-children-and-adolescents-serious-emotional-disturbance-who-get-treatment-mhmd-d01(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Magnus, W., Nazir, S., & Anilkumar, A.C. (2023). Attention Deficit Hyperactivity Disorder. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441838/(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Mohan, L., Yilanli, M., & Ray, S. (2023). Conduct disorder. In: StatPearls [Internet]. StatPearls Publishing.

Sagar, R., Patra, B. N., & Patil, V. (2019). Clinical Practice Guidelines for the management of conduct disorder. Indian journal of psychiatry, 61(Suppl 2), 270–276. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_539_18(Comprehensive Psychiatric Evaluation of a Patient with Conduct Disorder)

Zhang, J., Liu, W., Zhang, J., Wu, Q., Gao, Y., Jiang, Y., Gao, J., Yao, S., & Huang, B. (2018). Distinguishing Adolescents With Conduct Disorder From Typically Developing Youngsters Based on Pattern Classification of Brain Structural MRI. Frontiers in human neuroscience, 12, 152. https://doi.org/10.3389/fnhum.2018.00152