WEEK6-CHILD/ADOLESCENT PSYCHIATRIC INITIAL INTERVIEW/ASSESMMENT

Name: RX

DOB: 17

Minor:

Accompanied by: The father

Demographic: Caucasian

Gender Identifier Note: Female

CC: Patient complains, “I feel sad. I dream of my death, I cannot sleep at night, and I am scared.”

HPI: TX has experienced an inability to concentrate in school in the past month. Her school performance has deteriorated, and she has lost interest in school with the “school bus.” TX insists that the father must take her to school in his car, yet she feels restless when inside a vehicle and persistently worries about his father’s safety whenever he leaves home in his car. TX’s problem started a month and a half ago when her mother died from a road accident while she survived. Two weeks later, their school bus driver lost control, ramming into a roadside shop. She says “death is following her” and feels guilty about not helping her mum during the accident. Since then, TX has been acting “strangely,” having nightmares and sleepless nights. She feels comfortable sleeping with her father watching over her at night in her room. She has lost interest in school activities, is detached from friends, and is afraid of walking sideways. She is scare of horns and noise from people and television. At school, she does not listen to the teacher or instructions. She feels sad and worthless. Moreover, she misses her much. She would do anything to “go where she is.”

Pertinent history in the record and from the patient: None reported.

During assessment: The patient describes their mood as sad and has consistently gotten worse.

Patient self-esteem appears low, reports excessive guilt, sleep disturbance, change in appetite, energy, concentration, and memory.

The patient does not report increased activity, euphoria, or risky behaviors. The patient reports normal speech.  The patient experiences worry and fear.

The patient reports no hallucinations, delusions, obsessions, or compulsions.  The patient does not report symptoms of an eating disorder. The patient has a 2-pound weight loss in the last month.

SI/ HI/ AV: Patient denies SI/HI, SIBx, illegal/inappropriate, or violent behavior.

Allergies: NKDFA.

Past Medical Hx:

Medical history: Denies cardiac, respiratory, endocrine, and neurological issues.

The patient denies a history of chronic infection, including MRSA, TB, HIV, and Hep C. No surgical history was reported

Past Psychiatric Hx:

Previous psychiatric diagnoses: ADHD and specific phobia to darkness.

Describes deteriorating course of illness.

Previous medication trials: None reported.

Safety concerns:

History of Violence to Self:  None reported

History of Violence to Others: None reported

Mental health treatment history discussed:

History of outpatient treatment: None reported

Previous psychiatric hospitalizations: None reported

Prior substance abuse treatment: None reported

Trauma history: No history of trauma

Substance Use: Denies abuse of narcotics, ETOH, or alcohol.

Current Medications: Paroxetine for anxiety and depression.

Past Psych Med Trials: None reported.

Family Medical Hx:

Family Psychiatric Hx:

Substance use: None

Suicides: None

Psychiatric diagnoses/hospitalization: None

Developmental diagnoses: None

Social History:

Occupational History: No employment history.

Military service History: No previous military history.

Education history: The patient is in 12^th grade.

Developmental History: Normal childhood development.

Legal History: No legal issues.

Spiritual/Cultural Considerations: Christian.

ROS:

Constitutional:  No report of fever. Report weight loss.

Eyes:  Wear reading glasses.

ENT:  Normal hearing changes. No sore throat.

Cardiac:  No chest pain.

Respiratory:  No cough or wheeze.

GI:  No report of abdominal pain.

GU:  No dysuria or hematuria.

Musculoskeletal:  No joint pain.

Skin:  Normal skin turgor.

Neurologic:  No blackout, seizures, or numbness.

Endocrine:  No polyuria or polydipsia.

Hematologic:  No easy bleeding.

Reproductive: Sexually inactive. No abortions, miscarriages, pregnancies, hysterectomy. Last menstruation 01/10/2021

Include demographics, chief complaint, subjective patient information, and the names and relations of others present in the interview.

HPI:

, Past Medical and Psychiatric History,

Current Medications, Previous Psych Med trials,

Allergies.

 Social History, Family History.

Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative except for….”

Temp:

BP: 120/74

HR: 89

R: 18

O2: 96

Pain: None

Ht: 5”2”

Wt: 100lbs

BMI: 19.5 kg/m²

BMI Range: Healthy weight

LABS:

Lab findings WNL

Tox screen: Negative

Alcohol: Negative

HCG: N/A

Physical Exam:

MSE:

The patient is cooperative and knowledgeable, appears acutely distressed, and is fully oriented x 4. Patient is well-kempt. Normal psychomotor activity.

Eye contact avoidant, sad affect – restricted, even, congruent with a reported mood of “sadness.”

Speech: expansive, normal rate, variable volume/tone with difficulty finding words.

TC: no abnormal content elicited. Thought content is linear, coherent, goal-directed.

Cognition is intact with limited attention span & concentration.

Judgment and insight appear fair.

The patient can communicate needs, is encouraged, and is willing to comply with a treatment plan.

Vitals,

**Physical Exam (if performed, will not be performed every visit in every setting)

Include relevant labs, test results, MSE, risk assessment, and psychiatric screening measure results.

Dx: – PSTD. ICD-10 code is. Symptoms include exposure to death, serious injury or sexual violence, intrusion symptoms, avoidance, altered cognition, and mood. This is the primary diagnosis.

Dx: – MDD. ICD-10 code F32.1. Symptoms include depressed mood, weight loss, insomnia, fatigue, worthlessness, and inability to concentrate. This diagnosis is refuted.

Dx: – ODD. ICD-10 code F91.3. Symptoms include a pattern of irritability, vindictiveness, defiant behavior, and argumentativeness (APA, 2013). This diagnosis is refuted.

Dx: – Conduct Disorder Adolescent-onset type. ICD-10 code F91.2. Symptoms include aggression, deceitfulness, theft, and violations of rules (APA, 2013). This diagnosis is refuted

Dx: – ADHD. ICD-10 code F90.0. Symptoms include patterns of hyperactivity, impulsivity, and inattention that affect social function (APA, 2013). This diagnosis is refuted

The patient can respond to psychotherapy and appears to understand the need for medications, and is willing to maintain adherence.

Reviewed potential risks & benefits, Black Box warnings, and alternatives, including declining treatment.

Informed Consent Ability

(Note some items may only be applicable in the inpatient environment)

Pharmacologic interventions:

·         Titrate Paroxetine to 20 mg PO qDay initially, with the possibility of further titration depending on response 50 mg/day. The FDA recommends Paroxetine to treat PSTD symptoms (APA, 2017; Huang et al., 2020).

·         Psychotherapy referral for cognitive behavioral therapy (twice per week). In psychotherapy, the therapist helps clients restructure their memory to optimistic/realistic memories to replace the painful, destroyed (Watkins, Sprang & Rothbaum, 2018).

·         Education:

Importance of adherence to the treatment plan.

Discussed worsening symptoms, side effects of medication, and when to contact the ED.

Referrals: Psychotherapist

Follow-up: Return after 2 weeks for reassessment and further clinical recommendation.

Time spent in Psychotherapy  25 minutes

The visit lasted 60 minutes

Date: 10/15/2021    Time: 10pm