Psychiatric Evaluation

Psychiatric Evaluation

Demographic Information

Identifying Information:

Patient Initial: G. B.

Age: 16

Gender: male

Date of service: 6/06/24

SUBJECTIVE DATA

Chief Complaint: “Here for behavior issues.”

HISTORY OF PRESENT ILLNESS: (SUBJECTIVE).

The 16-year-old male African American patient is seeking initial evaluation, medication management, and counseling therapy due to escalating behavior-related difficulties that resulted in his school suspension. At the moment, he attends Scottsdale Unified School District’s Desert Mountain High School. His Individualized Education Program, or IEP, is in the eleventh grade of special education. Currently, he resides with his father, a single parent. His cleanliness, grooming, and appearance today was unremarkable. He was AOx1, reticent, irrational in his reasoning process, poor eye contact, disorganized speech and thinking, intellectually deficient, and occasionally rambling. His insight and judgment are lacking. He rarely paid attention to what was going on since he is easily distracted. He was seen to be concentrating intently on his five fingers all the while, paying little regard to the surroundings. He seemed to be reacting to internal cues that caused him to feel tense and nervous all the time. G.B.’s father and his grandmother (over the phone from Nigeria), answered the majority of the questions.

PAST PSYCHIATRIC HISTORY:

As per the records that are now accessible, G. B. was evaluated by Mobile Health Consult Brain Dynamics on April 9, 2022, in Nigeria. The findings of those tests supported his earlier diagnosis of ADHD. The outcomes also included DSM-V diagnoses for Specific Learning Disorder (SLD) and Autism Spectrum Disorder (ASD).

He was born vaginally, but his mother spent quite a long time at the hospital after giving birth before they came home. Nothing abnormal happened when she went into labor. While growing and developing, G. B. was a little behind schedule at age 2. He eventually regressed. Occasionally, he screamed when his dad exited the house. When his grandmother left him in the custody of a relative in Nigeria, his behavior deteriorated and became worse. He did not suffer any head injury. Grandma voiced worries about his speech style, stating that he occasionally talks to himself, acts aggressively, yells, “Leave me alone,” and seems to be seeing things. G. B. was brought to both a church and a spiritualist in Nigeria, according to his grandmother. In addition, he was registered for a special education course. Before he spoke to anyone, it took some time.

G.B. has behavioral problems, according to what his family stated. He acts erratically, has situational meltdowns, is agitated, has a tendency to punch or slap himself, has a history of losing control when out for a stroll with family, is internally distracted, and can be challenging to manage in a classroom. At home, he occasionally seems nervous and carries a blanket. He is said to have bitten his right hand and now has a scar on his hand. He is also characterized as being restless and fidgeting all the time. Last year, he saw a psychologist. He currently has a diagnosis for Cognitive Impairment, ADHD, and Autism. He has never taken medication in the past. He received a two-day school suspension due to misbehavior. He has never finished any assignments and is not typically assigned any. His level of sleep fluctuates. He is friendless. At home, he prefers to be by himself and typically exhibits none of the behavioral problems that his instructors have noted.

PREVIOUS PSYCHIATRIC MEDICATIONS: None

CURRENT MEDICATIONS: None

SUBSTANCE USE/ ADDICTIVE BEHAVIORS: None

FAMILY PSYCHIATRIC HISTORY:

His father and grandmother deny family history of mental health problems from his paternal side of the family. His mother’s biological sister has Autism and his mother is speech delayed. There is no family history of suicide. However, his paternal great grandfather was an alcoholic.

MEDICAL HISTORY:

He had a surgery between 4-5 years. Surgery was done under the tongue to improve his speech

PSYCHOSOCIAL:

G.B.’s parents divorced and dad got custody of him. Prior to their divorce, the home was toxic for the family due to family quarrels and fights. G.B. witnessed some of those fights until his grandmother took him from his parents. This happened when he was barely eleven months old. He has not been in the company of his mother since the divorce and she is not involved in his life. His grandmother is the mother he knows but she lives in Nigeria and comes to the United States once a year. Dad has not remarried and is in no relationship at the moment. He plays video games most of the time, when not in school.

He was born and raised in Chicago, Nigeria and Arizona. He is currently in high school on IEA (Special education). He is not married, an only child of his parents, has no living will, and his father is his psychiatric and medical power of attorney. He lives with his dad and he never experienced any abuse (physical, emotional, and sexual abuse). He is of African American decent.

G.B. is affiliated with the Christian religion, he is heterosexual, has no guns or weapons at home, drinks coffee daily. He denies taking sodas, and he exercises daily.

ASSETS/STRESSORS:

G.B is unable to concentrate in school. School stresses him out. He does not like people to hang around him.

OBJECTIVE DATA

MENTAL STATUS EXAM (MSE): (OBJECTIVE).

Appearance: clean, groomed, and appeared stated age
Behavior During Interview: restless
Eye Contact: minimal
Speech: impaired
Language: normal
Preferred Language: English
Gait and Station: unremarkable
Movement: normal strength and tone
Alert: yes
Oriented: person
Motor Activity: restless
Attention/Concentration: good
Mood: appropriate
Affect: unremarkable
Thought Content: absent
Delusions: absent
Hallucinations: none and denies
Suicidal: denied
Homicidal Ideation: denied
Violent Ideation: denied
Thought Process: unremarkable
Recent Memory: fair
Remote Memory: fair
Confusion: none
Insight: poor
Judgement: poor
Fund of Knowledge: fair
Intellectual Functioning: impaired
Patient Assets/Strengths for Treatment: stable

PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)

Vital signs BP 128/68 HR 86 Respirations 16 Temperature 98.3F O2 saturation 99% on room air height 5ft 9in and weight 166 Lbs. Reported pain in his nose 2/10.

Laboratory tests: CBC, CMP, TSH, Lipids, Hemoglobin A1c, Vitamin D

Psychiatric Impression:

A 16-year-old male African American patient is brought in for an initial evaluation in order to address a behavioral health condition that his school has noticed is getting worse. In the past, he had an autism and ADHD diagnosis. He struggles with speech and communication, is easily distracted, and finds it difficult to focus and socialize.

DSM 5:

F90.2 Attention-deficit hyperactivity disorder, combined type.

F84.3 Other childhood disintegrative disorder.

F39 Unspecified mood (affective) disorder.

DIFFERENTIAL DIAGNOSIS:

The patient’s history and current symptoms led to the consideration of the following differential diagnoses.

F72 Learning Disability/Intellectual Disability (LD/ID)
F84.0 Autism Spectrum Disorder (ASD)
Childhood Disintegrative condition (CDD) is a rare and little-studied developmental condition characterized by regression in language and social skills. According to Ellis et al. (2022),

Childhood Disintegrative Disorder (CDD) is rare and a child with CDD often develops normally for two years or more before seeing a significant and irreversible decline in their social and cognitive abilities, just like what happened to G. B. Patients with CDD have behavioral characteristics that resemble autism after regression (Ellis et al., 2022). However, the late age of regression onset and the patient’s seemingly normal development before to it are usually seen as special characteristics of CDD and are indicators that distinguish it apart from other diagnosis of autism spectrum disorder (Ellis et al., 2022).

There are two very important reasons why LD/ID is a differential for other childhood disintegrative disorder. This is because it is confirmed that many children with this disorder can also have some degree of LD (APA, 2022, pg. 31-33). Second, because children with LD frequently engage in repeated behaviors for a variety of reasons and it is common to misinterpret them for having Autism (APA, 2022, pg. 33, 50). A developmental examination will show that children with LD have linguistic skills that are commensurate with their cognitive capacities. Additionally, compared to children with Autism, children with LD exhibit greater nonverbal communication skills and a respectable level of emotional reciprocity (APA, 2022, pg. 33, 50). ADHD symptoms can coexist with those of other physical and mental health issues, including substance misuse, anxiety disorders, mood disorders, and hyperthyroidism and might be confused with those of other medical illnesses, drug interactions, sleep apnea, lead toxicity, seizure disorder, and brain injuries (Srichawla et al., 2022). With lab tests, imaging, and clinical presentation, the majority of them may be ruled out.

DIAGNOSTIC IMPRESSION WITH FORMULATION:

Attention-deficit hyperactivity disorder, combined type, F90.2 (ICD-10)

Periods of developmentally inappropriate attention, motor restlessness, and impulsivity are common characteristics of ADHD and can have a big influence on a person’s life at work and at home (Stahl, 2022). G.B. requires a diagnosis of ADHD, mixed type because he exhibits at least six symptoms of impulsivity/hyperactivity and at least six symptoms of inattention (American Psychiatric Association, APA, 2022). Maladaptive symptoms that have persisted for at least six months are necessary for the diagnosis of ADHD. Numerous factors, including both genetic and environmental components, are linked to the etiology of ADHD. Among the mental illnesses, it is among the most inherited. Siblings who have a common parent have twice the likelihood of developing ADHD. Pharmacological treatment is the cornerstone for treating ADHD (Magnus et al., 2023).

RISK ASSESSMENT:

The patient’s possible dangers to oneself and others were evaluated. The patient disputes having suicide thoughts or intent. He also disputes any thoughts of murder. However, he has been biting his own hand and left a scar (evidence of a wound at some point) and has been observed slapping himself. There is no evidence of substance use.

RECOMMENDATIONS AND PLAN

Medication for ADHD aims to decrease psychomotor activity, increase working memory, enhance attention, and lessen disruptive behavior (Stahl, 2022). Both stimulants and nonstimulant drugs can be helpful, but because of their shown effectiveness, stimulants are still the first choice for treating adult ADHD (Stahl, 2022). ADHD may be caused by genetic, environmental, or anatomical abnormalities in the brain. ADHD is linked to deficiencies in the neurotransmitters norepinephrine and dopamine. In order to enhance attentiveness, concentration, and wakefulness, it is necessary to increase norepinephrine and dopamine in specific brain regions, such as the dorsolateral prefrontal cortex (Stahl, 2022, p. 449-450). The symptoms of hyperactivity may also be alleviated by increased dopamine in the basal ganglia (Stahl, 2017, p. 455).

Similar to this, Magnus et al. (2023) indicated that fetal alcohol exposure, dietary deficiencies, smoking during pregnancy, and viral infections have also been investigated as potential causes of the disease. However, consistent results on brain imaging of ADHD individuals are lacking, the quantity of dopaminergic receptors have also been linked to the onset of the condition (Magnus et al., 2023). Additionally, there is proof that noradrenergic receptors play a part in ADHD.

G.B. will be admitted to outpatient care and stabilization to prevent worsening of behavior issues and address risk of self-harm and harm to others. He will follow up with all scheduled medical appointments with PCP and to focus on his school program. His father will complete the ADHD Assessment tools for the parent and return to provider while his teacher will complete the ADHD Assessment tools for the teacher and return to provider. The patient will participate in therapeutic groups and milieu activities on a consistent basis. No baseline labs will be ordered. G.B. will return visit in 2 weeks to discuss current treatment plan and discuss the results of the ADHD Assessment tools. Patient and Parent were educated that G.B. should practice sleep hygiene on a regular basis and participate in therapeutic groups and milieu activities on a consistent basis. The patient should maintain sleep hygiene, healthy weight, regular exercise, eat healthy and do not smoke.

At this clinic, counseling, care coordination, setting goals for health stability and psychotherapeutic interventions were initiated and done for the patient. The doctor did not want to place patient on any medications for now until the teacher and parent return the NICHQ Vanderbilt Assessment feedback to him. After which, if it confirms ADHD symptoms, G.B. will be started on Methylphenidate 5 mg tablet. He will take 1 tablet in the morning and at lunch for concentration and hyperactivity.

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