Symptom Analysis Evaluation #2

Symptom Analysis Evaluation #2

Chief complaint: “I don’t apologize and I don’t talk about my feelings.”

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HPI: Dan is a 15 years old African American male who was admitted into the inpatient unit under temporary detention order by the court. Dan was admitted for psychiatric evaluation due to physical aggression towards staff members at the group home where he’s been staying for about four months. Dan said that the staff member was “running his mouth.” Before the attack, Dan had told the staff member to shut up when asked to clean his room. The staff then confronted him for being disrespectful, but Dan began to raise his voice, attacked the staff member, and broke a piece of furniture. He expressed no remorse about the injuries he inflicted on the staff. Admits to the history of bad dreams and nightmares, denies obsessive thoughts, denies hallucinations, and paranoia but reports that he sometimes thinks he hears his name yelled out when no one is around. He denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue.

Psychiatric History: Preschool- behavioral problems with aggression towards peers, a problem with speech articulation, fell behind in the academics; elementary school- bedwetting, aggression, defiance, bossiness, poor sleep. Saw psychiatrist for the first time in elementary school and was tried on a high dose of stimulant. He was also prescribed clonidine and imipramine around the same time. In middle school, he was charged with assault after attacking a peer as a result of jealous rage and referred for anger management. Past psychiatric medication trials- Dextroamphetamine/amphetamine (not helpful), clonidine and imipramine

Past Medical History: Dan has seasonal allergy.

Surgical History: No surgical history

Family Medical / Psychiatric History: Mother has undiagnosed bipolar disorder and PTSD from sexual abuse by an uncle as a teenager, cocaine addiction, high cholesterol, and obesity. Father- Untreated bipolar disorder, anger issues, repeated incarceration.

Social History: Lives in a group home, CPS placement due to neglect and abuse since kindergarten. Dan took care of the younger brother for the most part due to his mother’s ongoing addiction issues, denies a history of tobacco use and substance abuse. Dan is in 8th grade, receives extra help at school, and on Individual Educational Plan (IEP).

Family History- Dan was physically and emotionally abused by his father. Mother has substance abuse and was never home when the patient lived at home.

Review of Systems: 10-system ROS negative except symptoms noted in HPI.

Medications: None

Allergies: NKDA

Vital Signs: BP 108/60 HR 62bpm, T 98.9F, RR 12/min Weight 140lbs without significant recent changes.

 

SAE Instructions

 

Review the above case study and complete the SAE assignment. Please use the SAE template that is provided in blackboard to complete the assignment and follow the instructions. Remember to use appropriate APA in-text citations and reference list. SAE is due by Sunday at 11:59pm (ET).

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