solved

Subjective:
CC (chief complaint): “I was attacking mom.”
HPI: K.B. is a 9-year-old male accompanied by parents with a history of ADHD and Disruptive mood dysregulation disorder (DMDD) presenting for aggressive behaviors at home. The mother stated that he recently changed his school three months ago. A week ago, the patient was recently discharged from Cape Fear Valley Hospital emergency room after presenting for similar behaviors. The patient has aggressive behaviors and failed outpatient psychotherapy. He reports aggressive behaviors towards his mother without identifiable triggers, and he denies suicidal thoughts or self-injurious behaviors. He endorses homicidal ideations without plan towards his mother and younger brother. He denies auditory and visual hallucinations and does not appear to be responding to internal stimuli during the assessment. He does not have symptoms consistent with mania or hypomania. He denies significant anxiety. The parents report that he takes his prescribed medications at home. He denies having difficulty with sleep at home and maintains a good appetite. Father says that the patient has been physically aggressive towards his mother for the past few days. He also indicates that the patient receives intensive in-home therapy three times a week but has not improved with treatments. Father reports the patient often stays up at nighttime despite compliance with medications. Father states that the patient had genetic testing outpatient to determine suitable psychotropic medications and provided documentation with results. Father reports concern about the family’s safety with the patient’s recent behaviors without further inpatient treatment.
Past Psychiatric History:
General Statement: He has a history of ADHD and Disruptive mood dysregulation disorder (DMDD). He currently has intensive in-home therapy 3 x a week.
· Caregivers (if applicable): Father and mother.
· Hospitalizations: No history of hospitalization in the past.
· Medication trials: Multiple
· Psychotherapy or Previous Psychiatric Diagnosis: History of ADHD (attention deficit hyperactivity disorder), Bipolar 1 disorder, and DMDD (disruptive mood dysregulation disorder).
Substance Current Use and History: No history of alcohol, drug, or tobacco, caffeine use,
illicit drugs use, or exposure to secondhand cigarette smoke.
Family Psychiatric/Substance Use History: It is unknown family psychiatric or substance
history because he was adopted at age 2. No family history of suicide or homicide. The parents
deny any substance abuse problems.
Psychosocial History: The patient was adopted at age 2, was placed in foster care due to neglect
by parents. Education: fourth grade at elementary school, was homeschooled before September
of this year.
Family/Living situation: He lives with his parents, 8-year-old brother, and multiple dogs at
home. He was born and raised in North Carolina. He does not have past or current legal issues—
no history of trauma and no history of any violence or abuse.
Medical History:
· Current Medications: Clonidine 0.1 mg every morning and afternoon, 0.2 mg at nighttime.
Prozac 20 mg daily; Zyprexa 5 mg BID; Focalin 10 mg daily; Depakote 750 mg nightly;
melatonin 3 mg nightly; Remeron 7.5 mg nightly
· Allergies: Penicillin
Reproductive Hx: He is not sexually active.
ROS:
· GENERAL: He denies fever, recent weight gain, recent weight loss, chills, or intolerance to
heat or cold.
· HEENT: Head: He denies head trauma, dizziness, seizures, or headache. Eye: He denies
blurring of vision, eye pain, loss of vision, or eye discharge. Ear: He prohibits tinnitus, vision loss, ear discharge, and ear pain. Nose: He denies running nose, nose bleeding, sneezing, or nasal congestion. Throat: He denies sore throat, painful swallowing, hoarseness of voice, or difficulty in swallowing.
· SKIN: He denies itchiness or rashes.
· CARDIOVASCULAR: He denies edema, palpitations, chest pains, orthopnea, or shortness of
breath.
· RESPIRATORY: He denies cough, chest pains, fast breathing, sputum production, or difficulty
breathing.
· GASTROINTESTINAL: He has a history of losing appetite but denies abdominal pains,
diarrhea, nausea, vomiting, or constipation.
· GENITOURINARY: He denies burning sensation during urination, incontinence, hematuria,
hesitancy, or oliguria.
· NEUROLOGICAL: He denies dizziness, headache, syncope, numbness, ataxia, tingling
sensations, and paralysis.
· MUSCULOSKELETAL: He denies back pains, muscle pain, joint stiffness, or joint pain.[1]
Objective:
Physical examination: No physical examination will be needed for this patient.
Diagnostic results: complete blood count (CBC), comprehensive metabolic panel (CMP) tests necessary to rule out the anemia. Any infection, examine electrolytes to rule out renal disorder, and a thyroid function test to rule out thyroid disease. Blood studies and immunological evaluation for commercially were conducted. Platelet count was the only blood boundary for control status that was statistically significant (p=0.01) in a regression model controlling for age and gender differences (KRIVOSOVA et al., 2020).
Depakote level needs to be checked to maintain a therapeutic level. Plasma drug quantitation is used to check dose titration, compliance, and toxicity in treatment with antiepileptic drugs like valproic acid (VPA). However, without considering the pharmacokinetic principles due to the absence of clinical pharmacists in the Health System (del Rosario Hernández-Jerónimo et al., 2021). The diagnostic test conducted on the patient is a children’s depression inventory (CDI); according to Ahlen & Ghaderi (2017), The Children’s Depression Inventory-Short Version widely used Children’s Depression Inventory has been extensively used in recent research.
Assessment:
Mental Status Examination: He is a young Caucasian boy who is well-groomed, dressed appropriately. Behaviors are normal posture and sitting up in a chair—no apparent tics or tremors. Patient with good eye contact and is cooperative. Speech is regular in rate, rhythm, volume and is spontaneous. Thought processes are linear. Both his short-term and long-term memory is intact. He denies auditory and visual hallucinations and does not appear to be responding to internal stimuli. Thought content is without apparent delusions or paranoia. He reports his mood is “slightly depressed.” Affect is mildly dysphoric and mood congruent. The patient denies suicidal ideations, denies suicidal plans, endorses homicidal ideations, and denies homicidal intent. He is awake and alert—he has impaired concentration. Insight is limited. Judgment is limited. Reliability reveals patient dependable in interview information. He is oriented to person, place, and time. His cranial nerves were all intact.
Differential Diagnoses:
Disruptive mood dysregulation disorder (DMDD): According to DSM 5, severe recurrent temper outbursts manifested verbally and behaviorally out of portion to the situation, and inconsistent with developmental level Mood between bursts is persistently irritable or angry (American Psychiatric Association. 2013). DMDD describes behavior that is thought the abnormal range of childhood behavior; the crucial features of this disorder include severe recurrent temper outbursts manifested verbally and behaviorally that are out of portion in strength or duration to the situation or incitement (Gilea & O, N. R. M.,2015).
Pediatric major depressive disorder: Mental disorders affect 10-20 % of the young population in the world. Major depressive disorder (MDD) is a usual mental disease with a multifactorial and unclearly mentioned pathophysiology. Many cases stay undetected and untreated, which influences patients’ physical and psychological health and quality of life in adulthood (KRIVOSOVA et al., 2020). DSM 5 stated that depressed mood; loss of interest in activities or pleasure(anhedonia); insomnia or hypersomnia, agitation; fatigue or loss of energy; excessive guilt; decreased ability to concentrate; thoughts of death or suicide (American Psychiatric Association. 2013).
Pediatric bipolar disorder (PBD): DSM 5 listed persistently elevated or irritable mood; persistently increased energy or activity. Mania: inflated self-esteem or grandiosity; decreased need for sleep; pressured speech; racing thoughts distractibility; risky behavior (American Psychiatric Association. 2013). According to Gao et al. (2021), The present findings suggested that psychotic features in PBD were associated with extensive brain structural lesions located in the prefrontal-limbic-striatum circuit, which might represent the pathological basis of more severe symptoms in patients with psychotic PBD.
Pediatric generalized anxiety disorder: DSM 5 reports excessive distress with separation from home or caregivers; persistent worry about harm to caregivers; excessive worry about untoward event separating from a caregiver; extreme reluctance to be alone; ongoing separation; repeated physical symptoms when separating. Persistent problems or worry about attacks; significant behavior changes related to attack (American Psychiatric Association. 2013). Pediatric anxiety disorders are known, impairing, and often undertreated. Moreover, many youths do not respond to standard, evidence-based psychosocial or psychopharmacologic treatment. An increased understanding of the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems has created opportunities for novel intervention development for pediatric GAD (Sonmez et al., 2020).
Reflections: I would first welcome the patient and his parents to the clinic to be comfortable. At first, I introduce myself. I would also for sure the parents inform them that everything that will be discussed will be confidential and therefore they should share everything that will be helpful.
Confidentiality: Maintaining confidentiality is an important way of adolescent health care. Different states and places have laws around confidential health care to minors for specific health concerns such as mental health and substance abuse. However, in situations where confidentiality cannot be assured if the adolescent is being abused. Educating teens and parents about the problems in which confidentiality is necessary (Alderman, 2017).
Ethical consideration: Rohan & Winter (2021) reported, children with chronic illnesses often have complex treatments that not only necessary a great deal of time and effort to manage but will also likely impact relationships with parents, siblings, and peers. Collaborating with a psychologist can help alleviate these unique challenges, positively impacting health behaviors and health outcomes.
Health Promotion: children’s primary care teams are routinely involved in many activities helping caregiver health, independent of training background despite many practice-related barriers. Co-location of support services could care the efforts of pediatric care teams. Future actions investigating care models that address these barriers and facilitators will help realize pediatric settings’ potential to impact adult health (Venkataramani et al., 2017). The health promotion of pediatric mental disorder educates the patient about his diagnosis and his family members about the condition. The family members are also critical since they will administer his prescribed treatment and ensure compliance.
Case Formulation and Treatment Plan: The patient demonstrates an elevated risk of harm to self or others currently. The patient requires medically necessary Inpatient Psychiatric Hospitalization to maintain safety and progress in treatment made to date. The discharge would cause regression of progress made and lead to rapid readmission. I would ensure that I remain attentive and maintain eye contact throughout the assessment. The assessment will also be performed in an orderly and professional manner and respect the parent’s decision not to answer or share any information. If it is urgent symptoms, decompensation, or thoughts of self-harms, call 911 or go to the emergency room. Mobil Crisis management is also available 24 hours and every day.
References
Ahlen, J., & Ghaderi, A. (2017). Evaluation of the Children’s Depression Inventory—Short Version (CDI-S). Psychological Assessment, 29(9), 1157.
Alderman, E. M. (2017). Confidentiality in Pediatric and Adolescent Gynecology: When We Can, When We Cannot, and When We are Challenged. Journal of Pediatric and Adolescent Gynecology, 30(2), 176-183. https://doi.org/10.1016/j.jpag.2016.10.003
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Https:///doi.org/101176/appi.books.9780890425596
del Rosario Hernández-Jerónimo, M., Chehue-Romero, A., Guadalupe Olvera-Hernández, E., Reyes-Hernández, I., Bermúdez-Camps, I. B., Ruíz-Anaya, M. E., & Robles-Piedras, A. L. (2021). Evaluation of the Appropriateness of Valproic Acid-Levels Monitoring in Mexican Pediatric Patients. Archives of Pharmacy Practice, 12(2), 1-5. https://doi.org/10.51847/rZTVWrCI1k
Gao, W., Cui, D., Jiao, Q., Su, L., Yang, R., & Lu, G. (2021). Brain structural alterations in pediatric bipolar disorder patients with and without psychotic symptoms. Journal of Affective Disorders, 286, 87-93. https://doi.org/10.1016/j.jad.2021.02.077
Gilea, B. L., & O, N. R. M. (2015). Disruptive Mood Dysregulation Disorder. School of Counseling Publications.
KRIVOSOVA, M., GRENDAR, M., HRTANEK, I., ONDREJKA, I., TONHAJZEROVA, I., SEKANINOVA, N., BONA OLEXOVA, L., MOKRA, D., & MOKRY, J. (2020). Potential Major Depressive Disorder Biomarkers in Pediatric Population – a Pilot Study. Physiological Research, 69, S523-S532.
Rohan, J. M., & Winter, M. A. (2021). Ethical considerations in pediatric chronic illness: The relationship between psychological factors, treatment adherence, and health outcomes. Pediatric Respiratory Reviews, 39, 48-53. https://doi.org/10.1016/j.prrv.2021.05.008
Sonmez, A. I., Almorsy, A., Ramsey, L. B., Strawn, J. R., & Croarkin, P. E. (2020). Novel pharmacological treatments for a generalized anxiety disorder: Pediatric considerations. Depression and Anxiety, 37(8), 747-759. https://doi.org/10.1002/da.23038
Venkataramani, M., Cheng, T. L., Solomon, B. S., & Pollack, C. E. (2017). Caregiver Health Promotion in Pediatric Primary Care Settings: Results of a National Survey. The Journal of Pediatrics, 181, 254-260. https://doi.org/10.1016/j.jpeds.2016.10.054

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