1. Comprehensive Psychiatric Evaluation Note Discussion Paper
Comprehensive Psychiatric Evaluation Note Discussion PaperIntroductionIn diagnosing
behavioral, emotional, or developmental disorders, a comprehensive psychiatric evaluation
is essential. An evaluation of a child, adolescent, or adult is conducted dependent on current
behaviors and how they relate to physical, emotional, genetic, social, environmental,
cognitive (thinking), and educational factors that could be impacted by these behaviors. For
those with a mental health condition, family involvement and continued engagement in
therapy are critical after a diagnosis has been established. By partnering with family
members to develop short-term and long-term treatment goals for their loved ones,
healthcare professional or mental health specialist can address concerns to provide
emotional support. This paper is a comprehensive psychiatric evaluation note for Jake, a
patient who was brought to the clinic by his mother with complaints of aggressiveness and
irritability Comprehensive Psychiatric Evaluation Note Discussion Paper.ORDER A
PLAGIARISM-FREE PAPER HEREComprehensive Psychiatric Evaluation NoteCC (chief
complaint): “My son has been irritable and hostile.”HPI:. Jake, a 13-year-old boy, is brought
to the hospital by his mother, who says he has been bad-tempered and hostile for
seven months. According to the patient's mother, the patient has lately started whining
about minor issues and shoplifting more often. She even says the boy has declined to go to
school. The patient had beaten his sister severely the week before, nearly injuring her. The
patient appears to be defiant and unwilling to speak.Past Psychiatric History: the client does
not have a past psychiatric historySubstance Current Use and History: denies alcohol use
and cigarette smoking. Denies illicit drug abuseFamily Psychiatric/Substance Use History:
no family psychiatric and substance use history.Psychosocial History: jake was born and
brought up and lives in Maryland by both of his parents and two siblings.. He is the
youngest, of three children with a brother and a sister. The patient, along with her sister
and two children, currently resides in Michigan. She has a bachelors degree in Economics.
He has been attending elementary school but lately refuses to attend school. His hobbies
playing video games and watching movies. The client’s mother claims the boy has been
involved in several indiscipline and disciplinary cases in school. .Medical History:Current
Medications: NoneAllergies: PenicilinROS:GENERAL: No fatigue, weakness, chills, fever, or
weight loss.HEENT: Eyes: No yellow sclerae, double vision, blurred vision, or visual loss.
Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.SKIN:
No itching or rash.CARDIOVASCULAR: No chest discomfort, chest pressure or chest pain.
No edema or palpitations.RESPIRATORY: No sputum, cough, or shortness of
2. breath.GASTROINTESTINAL: No diarrhea, vomiting, nausea, or anorexia. No blood or
abdominal pain Comprehensive Psychiatric Evaluation Note Discussion
Paper.GENITOURINARY: No odd color, hesitancy, odor, urgency, or burning on
urination.NEUROLOGICAL: No tingling in the extremities, numbness, ataxia, paralysis,
syncope dizziness, or headache. No change in bladder or bowel
control.MUSCULOSKELETAL: No stiffness, joint pain, back pain, or muscle
pain.HEMATOLOGIC: No bruising, bleeding, or anemia..LYMPHATICS: No history of
Splenectomy. No enlarged nodes.ENDOCRINOLOGIC: No polydipsia or polyuria. No heat
intolerance, cold, or sweating.Physical exam:Height: 5'0" Weight: 90 pounds BMI:
17.6 BP: 111/71 P: 72 regular R: 18Heart: Regular rhythm and hearbeat.Lungs: Normal
respirations.Appearance: Steady gait. He is neatly dressed.General behavior: He does not
maintain eye contact and is unwilling to speak.Attitude: The patient is displays annoyance
and anger when being asked questions.Orientation: Oriented to place, time, and person.LOC:
alert.Thought process: Not goal-directed. Not willing to be helped.Thought content: Appears
angry, has a hostile behavior.Judgment: Patient. is unwilling to know the problem he has,
does not understand the facts, and is not ready to walk with us in the recovery
process.Diagnostic results: No relevant diagnostic test performedAssessmentMental Status
Examination:He is a 13-year-old Caucasian male who looks the stated age. He is not
cooperative with the examiner as he refuses to speak. He is neatly dressed, clean, and
groomed appropriately. There is no evidence of any abnormal motor activity. The client
does not maintain eye contact throughout the examination. He appeared to have shifting
thoughts. His mood is dysthymia, and his affect appropriate to his mood. He appeared
gloomy throughout the examination. He is cognitively oriented and alert. His remote and
recent memory is intact. He displays concentration problems as he keeps using his phone.
He has good insight Comprehensive Psychiatric Evaluation Note Discussion
Paper.Differential DiagnosesPrimary Diagnosis: Conduct disorderConduct disorder is a
mental problem that most often affects children and teenagers. Aggression against persons
or animals, property damage, deception or stealing, and severe rule violations are all
symptoms of this disorder (Kazdin, 2018). Based on the symptoms displayed by Jake, he
most possibly has conduct disorder. This is because he has been having hostile and
aggressive behavior towards everyone at home and school, and he beat his sister last week
to a point of injuring her. The father mentions that the client has also been shoplifting and
has been truant. The boy’s symptoms began 7 months ago, therefore meeting the DSM-5
criteria for conduct disorder. The primary diagnosis in this patient is aligned to the DSM-5
criteria through the depiction of symptoms of violation of rules including aggressive
behavior, theft, and serious violation of rules and this kind of behavior has clinically
impaired his social and academic life (American Psychiatric Association,
2013)Comprehensive Psychiatric Evaluation Note Discussion Paper.Oppositional defiant
disorderOppositional defiant disorder (ODD) is a behavior disorder where a child has a
habit of being agitated or cranky, behaving defiantly or combatively, and being vindictive
toward those in power positions (Frick, 2016). The person's behavior regularly disrupts
their everyday life, particularly home and school activities. There is some possibility that
Jake could be suffering from ODD, due to the symptoms he displays, such as a habit of being
3. cranky and behaving defiantly. However, the patient displays other symptoms like engaging
in theft, hence rendering conduct disorder the primary diagnosis.Intermittent explosive
disorder The intermittent explosive disorder is characterized by a pattern of impulsive,
angry, aggressive behavior, or violent behavior that is out of proportion to the circumstance
(Fairchild et al., 2014). It may manifest itself as road rage, domestic violence, hitting or
destroying stuff, or other angry outbursts. These sporadic, explosive outbursts trigger
severe distress, have a detrimental effect on your relationships, career, and education, and
can have financial and legal ramifications. The possibility of intermittent explosive disorder
in the client is shown when the father mentions that the boy has been getting angry over
small issues and displayed aggression when he beat his sister Comprehensive Psychiatric
Evaluation Note Discussion Paper.PlanCognitive-behavioral therapy (CBT) and peer group
therapy are recommended for this client (Dobson & Dobson, 2018). CBT will assist the
client in improving his problem-solving, communication, and stress-handling skills. It will
also assist him with learning to control his anger and impulses. Peer group therapy, on the
other hand, will help the child develop better interpersonal and social skills.ReflectionsI am
finding this evaluation to be quite fascinating. I had not thought about it, but I am steadily
gaining a better understanding of the many purposes underlying various types of therapy
that aid in the management of conduct disorder. These care options can help a patient
enhance his everyday activity. I would not have done anything differently because I believed
I had conducted a comprehensive evaluation of the client with my preceptor centered on
the patient's health condition, and I followed the correct clinical procedure with my
preceptor to achieve an acceptable primary and differential diagnosis, as well as a
treatment plan for the client's health problem.ConclusionConclusively, a comprehensive
psychiatric evaluation is a critical aspect of the skills of practitioners that helps in
understanding, diagnosing, and developing a treatment plan that best meets the needs of
clients with mental health issues. This paper has provided a comprehensive psychiatric
evaluation of a 13-year old boy who was presented to the clinic by his mother, who was
concerned about her son’s aggressive and hostile behavior. The comprehensive psychiatric
evaluation was critical as it established the patient’s diagnosis, which is conduct disorder.
The physical and mental status exam aided in finding out that the patient hand conduct
disorder. After the diagnosis, the most appropriate treatment plan was established to
ensure that the patient’s health needs were met and that he gets back to his normal life
Comprehensive Psychiatric Evaluation Note Discussion Paper.ReferencesAmerican
Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-
5®). American Psychiatric Pub.
https://www.psychiatry.org/psychiatrists/practice/dsmDobson, D., & Dobson, K. S.
(2018). Evidence-based practice of cognitive-behavioral therapy. Guilford
publications.https://doi.org/10.1002/9781118470138.ch12Fanti, K. A. (2018).
Understanding heterogeneity in conduct disorder: A review of psychophysiological
studies. Neuroscience & Biobehavioral Reviews, 91, 4-
20.https://doi.org/10.1037/mil0000092Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W.
E., Odgers, C. L., Franke, B., ... & De Brito, S. A. (2019). Conduct disorder. Nature Reviews
Disease Primers, 5(1), 1-25.https://doi.org/10.1080/20008198.2020.1824381. Frick, P. J.
4. (2016). Current research on conduct disorder in children and adolescents. South African
Journal of Psychology, 46(2), 160-174. https://doi.org/10.1007/978-3-319-07109-
1_10Kazdin, A. E. (2018). Implementation and evaluation of treatments for children and
adolescents with conduct problems: Findings, challenges, and future
directions. Psychotherapy research, 28(1), 3-17.https://doi.org/10.1007/s40501-020-
00207-xKyranides, M. N., Fanti, K. A., Katsimicha, E., & Georgiou, G. (2018). Preventing
conduct disorder and callous unemotional traits: preliminary results of a school based pilot
training program. Journal of abnormal child psychology, 46(2), 291-
303.https://doi.org/10.1093/med-psych/9780190926939.003.0003Sagar, R., Patra, B. N.,
& Patil, V. (2019). Clinical practice guidelines for the management of conduct
disorder. Indian journal of psychiatry, 61(Suppl 2),
270.https://doi.org/10.3389/fpsyt.2019.00650Sonuga‐Barke, E. J., Cortese, S., Fairchild, G.,
& Stringaris, A. (2016). Annual Research Review: Transdiagnostic neuroscience of child and
adolescent mental disorders–differentiating decision making in attention‐
deficit/hyperactivity disorder, conduct disorder, depression, and anxiety. Journal of Child
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349.https://doi.org/10.1017/9781107445130.024ORDER A PLAGIARISM-FREE PAPER
HERE Select a patient for whom you conducted psychotherapy for an impulse control or
conduct disorderduring the last 6 weeks. Create a Comprehensive Psychiatric Evaluation
Note on this patientSubjective:What details did the patient provide regarding their chief
complaint and symptomology to derive your differential diagnosis? What was the duration
and severity of their symptoms? How are their symptoms impacting their functioning in
life?Objective:What observations did you make during the psychiatric
assessment?Assessment:Discuss the patient’s mental status examination results. What were
your differential diagnoses? Provide a minimum of three possible diagnoses in order of
highest to lowest priority and explain why you chose them. What was your primary
diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic
criteria and is supported by the patient’s symptoms.Plan:What was your plan for
psychotherapy (including one health promotion activity and one patient education
strategy)? What was your plan for treatment and management, including alternative
therapies? Include nonpharmacologic treatments, alternative therapies, and follow-up
parameters, as well as a rationale for this treatment and management plan.Reflection
notes:What would you do differently with this patient if you could conduct the session
again? PLEASE INCLUDE INTRODUCTION AND CONCLUSION AND EXPLAIN DIFFERENTIAL
DIAGNOSIS USING AT LEAST A PARAGRAPGH OR TWO Comprehensive Psychiatric
Evaluation Note Discussion Paper
