Comprehensive Psychiatric Evaluation for Anxiety Symptoms

Week: Comprehensive Psychiatric Evaluation
Student Name
College of Nursing-PMHNP
PRAC 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
Comprehensive Psychiatric Evaluation
Chief Complaint
The patient’s chief complaints are anxiety symptoms since his mother reported excessive and constant worry and anxiety regarding different things.
HPI
SR, an 11-year-old African American male, presents for psychiatric evaluation for anxiety symptoms. He only uses Desmopressin (DDAVP) to manage bedwetting but has no prescribed psychotropic medications. The doctor referred him for psychiatric evaluation. The patient came for evaluation because of his extreme worry and anxiety symptoms, which are not associated with a specific trigger. The symptoms started when he was separated from his father at five. The constant symptoms have lasted up to this point, and they are very severe since he worries about negative things, such as death. As a result, he is stubborn, has sad moods, and sleep difficulties, has a low appetite, throws things around, and consistently complains of headaches or stomach aches.
Past Psychiatric History
The patient first entered treatment at the age of five years for separation anxiety disorder. The mother has been providing care to the patient following their separation from the father. The patient has been seeing a pediatrician, who prescribed DDAVP, but it has been ineffective. The patient has no history of self-harm behaviors. The mother never reported any previous psychotropic medications. The earlier diagnosis and treatments for separation anxiety disorders have not been helpful since he still experiences the symptoms at the age of 11 years.
Substance Use and Psychiatric Family History
The patient has no history of substance abuse or report of his family's psychiatric history.
Psychosocial History
The mother raised the patient and his younger brother, and they currently live together since they separated from their father. He is in the primary level of education and likes coloring as his hobby. He has no past specific triggers or traumatic events.
Medical History
He has no allergic reactions from his current medications of DDAVP that manages bedwetting.
ROS
Gastrointestinal
The general review of the gastrointestinal system reflects weight loss due to inadequate food intake.
Musculoskeletal
The general review of the musculoskeletal system shows no muscle tension.
Assessment
Mental Status Assessment
The 11-year-old male looked his age and had an intact orientation in time, place, and person. He is clean and well-dressed and has no abnormalities. He cooperated and concentrated during the examination and maintained eye contact while answering questions well with a coherent speech and tone. However, he was sad and looked distracted when looking at his mother. There is evidence of delusional thinking since his mother reported that he thinks he might die or that the mother likes the younger brother more than him. He had good insight and a logical and organized thought process. He denied suicidal ideation, delirium, harm to others, or hallucinations. He also has an intact memory with a good flow and association of ideas.
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