Psychiatric History Taking

Psychiatric History Taking. Demographic information. The patient is a 9-year old male child of American origin currently living in San Carlos street California. He lives with his parents in a one bedroom rental house. The patient speaks English and communicates well. The client is a Christian and goes to a nearby Catholic Church occasionally.

The information was obtained from the patient’s mother and confirmed by his father since the patient was uncooperative.

Presenting Problem

The patient’s mother states that “He was at school when he left his seat and went outside. When called back to class he did not respond but instead started moving around other rooms in the school compound.”

History of Present Illness

The patient appears calm and restless. He is oriented to time place and person. The mother reports that she noted unusual activities a week ago when the patient left his seat while taking lunch and went to play outside. Later in the day, the client was very active, climbing trees and flowers around the homestead and he talked a lot. The mother did not take it seriously but shared the abnormal behavior with her husband. Three days later, the mother received a phone call from school that the child was not attentive in class, always spoke before his turn and seemed to disobey commands from the teachers. Reports from his colleagues at school indicated that he was a bit violent while playing and talked a lot than usual. The parents were planning to seek medical advice over the weekend before the incidence at school happened.


Past Psychiatric History

The patient has a history of inattention noted since he was seven years old. The mother reports that when he was young, he could do multiple tasks at the same time while forgetting that he was doing something else. At home, the patient is reported to go out on his own, walk in the street and later come back home while restless. Much of the symptoms have been associated with school life. The mother reports that the child has a history of losing school items like books, pens, and attire. The child could sometimes come home without the books, and when asked where he left them he could not remember. Two years ago, the patient was assigned a therapist to try and detect if any psychiatric disorder was affecting the patient, but the sessions did not go far due to lack of capital. Last year, the mother noticed that the patient had loss of interest in his studies. He could avoid reading even during exam time, and when forced to read, he couldn’t keep his attention on the books. Poor performance has been observed since. No medications were used at that time, and the condition was seen to calm until a week ago.

Medical History

The client has been hospitalized three times in the past due to various conditions. The first event of hospitalization was in May 2013 due to head trauma. The mother reports that the patient fell from her back when she slipped on a wet floor and had a head injury. The patient was later diagnosed with acute head injury at the county hospital and treated for two months. According to the hospital reports, the doctors later realized that there was a subdural hematoma noted later after several tests, but it resided with treatment and observation.

The second episode of hospitalization happened in August 2015 when the patient broke his humerus after falling from the stairs. The patient was treated for three weeks and discharged home for regular checkups. The third event of admission was observed in December 2015 with a diagnosis of tonsillitis. The mother reports that he was hospitalized for three days and discharged home on medication. There were no records available on the medication used for management of the patient’s conditions. All the immunization schedules are up to date. Tetanus vaccine was given at the age of 6 years after the injury that led to hospitalization in December 2015. There is no history of hypertension, diabetes or other chronic illnesses in the patient.

Substance use History

There is no history of substance abuse in the past.

Developmental History

The patient is the first child in the family, and he has stayed with his parents since birth. There are no abnormalities on the mother’s side experienced during pregnancy, and she reports that the patient was born normally at a gestation of 39 weeks. He was born with a birth weight of 3.2kgs and lived a normal early childhood. The mother reports that breastfeeding was normal and he did not suffer from any life-threatening illnesses. The patient’s developmental milestones were normal as other children. At the age of four years, the patient had a head injury that led to hospitalization. The mother reports that since the injury, the normal growth of the child has not been good. He has had problems coping with other children and lacks interest in studies and other important activities. He started school at the age of four years.

Family Psychiatric History

The patient’s immediate family consists of his mother (age26) and his father (age 29). His father has a history of alcohol dependency reported to have started at the age of 18 years. His mother does not drink or smoke tobacco, but reports episodes of alcohol intake during her adolescent years. There is a history of alcohol and substance abuse in the family with the patient’s grandfather currently being an alcohol addict. There is no history of other psychiatric disorders apart from alcohol and substance abuse in the family.

Psychosocial History

The patient stays with his parents in a one bedroom rental house. The support system available is from the parents. Life conditions and interaction with the surrounding community is good as they stay in a homestead full of other children. The mother reports that the child is disturbed with learning, and he does not like going to school. Playing with other children is normal. Support system from the neighbors and friends is also good.

History of Abuse /Trauma

There is a history of head injury at the age of 4 years where the patient fell from the back of his mother. A year later the patient broke his humerus after falling from the bed. There is no history of abuse or harassment.

Review of Systems

HEENT: There are no complaints of a headache, visual impairment, hearing loss, nose problems or a sore throat.

Respiratory: The breathing rate is normal with a breathing rate of 20b/m. Chest expansion and recoil is good. No abnormal breath sounds detected.

Cardiovascular: The heart rate is at 78b/m, and the capillary refill is at 2 seconds. There is no central or peripheral cyanosis. No abnormal heart sounds felt on auscultation.

Gastrointestinal: There is no complaint of nausea and vomiting or swallowing problems noted. The consistency and pattern of stool are normal.

Genitourinary: No complaints of anuria, dysuria, polyuria or hematuria.

Musculoskeletal: Patients complains of tiredness after long walking hours associated with his hyperactivity but is relieved after a normal rest period.

Neurological: Patient is restless. Orientation to time, place and person is present.

Physical Assessment

Vital signs: Temperature is 36.7 degrees, pulse 78b/m, respiration 20b/m and blood pressure 126/84mmhg.

General Appearance: The patient is alert, well oriented and presentable.

HEENT: The scalp is normal with a good hair distribution. The pupils are normal, equal and reactive to light. The conjunctiva and the sclera are normal. The ear is clean with normal tympanic membranes. The nasal mucosa is normal. The mouth is clean, moist and pink in color.

Neck: The range of motion is normal. On palpation, the thyroid glands are normal.

Chest: The chest is normal, no scars observed. Expansion and recoil are good. On auscultation, the heart sounds are well heard with no murmurs.

Abdomen: There are no abdominal scars on inspection. It is symmetrical without distention, and the bowel sounds are normal. On palpation, the liver and the spleen are normal in size.

Limbs: The upper and lower limbs are symmetrical. Capillary refill is at 2 seconds. No cyanosis observed. Femoral, popliteal, brachial and radial pulses are present.

Genital/Rectal: The genitalia is normal, no enlargement of testes. No rectal masses on palpation. Client reports the normal passing of stool.

Mental Status Examination

Appearance: The patient is a young man appearing his speculated age on school uniform. He is clean, alert but unsettled. He appears restless irrespective of his random movements on the seat. His hygiene status is good, no physical injuries observed. He sits with his legs crossed and arms on the chair. He maintains poor eye contact and seems distracted by the surrounding features.

Speech: The patient speaks spontaneously with a normal tone and speed. He is sometimes interrupted and distracted by the environment. Articulation of words is good. The content of the speech is relevant to the topic of discussion.

Mood: Subjectively the patient reports feeling restless and happy. Objectively the patient is tensed, restless and worried. Emotional expression is labile.

Thought content: The patient is not preoccupied with any thoughts. He says he is okay and needs to go home after the exercise. He insists that nothing is wrong with his actions and he does not see anything wrong. He does not deny the claims presented by his parents.

Perception: No evidence of hallucinations or illusions noted.

Cognitive functions: The patient is alert throughout the session. He is oriented to time, place and person. The memory is good as he can recall recent, recent past, and remote memory.  The abstract thinking is good; he can give similarity between a mango and an orange, says both are fruits. On the assessment of insight, he accepts the claims that he has been unusual recently but does not see if anything is wrong with the situation. The judgment is excellent. He says that if someone angers him at school, he will report it to the class teacher.

Differential Diagnosis

Bipolar disorder: Bipolar disorder closely resembles ADHD because it presents with hyperactivity, distractibility and poor performance at school (Thomas et al., 2015). However, after complete health history and MSE, common symptoms of bipolar disorders such as grandiosity, racing thoughts, and reduced sleep were not observed ruling out the condition.

Anxiety disorder: Anxiety disorders are commonly known to present with signs of ADHD. PTSD is one disorder that presents with agitation, hyperactivity, motor restlessness, reckless behavior and poor concentration (Faraone, 2013). After investigation and history taking, the patient has had no major traumatic event in the past that can lead to the generation of the diagnosis.

Case Formulation

DSM-5 Code 314.01: Attention Deficit Hyperactivity Disorder

According to the DSM-5, ADHD is diagnosed with the presence of hyperactivity, inattention and impulsivity symptoms in the client affecting the occupational and daily functioning (American Psychiatric Association, 2013). The condition is also diagnosed when the symptoms are present before the age of 12 years. The patient 9-years old and initial symptoms indicate episodes of inattention and hyperactivity at school. At seven years, the first symptoms of inattention and hyperactivity were noted. Currently, the patient’s performance at school is poor, does not pay attention and fails to follow commands. The patient walks a lot during the day and behaves differently when with other children.

Treatment Plan

Methylphenidate   5mg Po BD

The dosage was chosen because the medication is indicated for use in ADHD. Methylphenidate is a stimulant that acts by stimulating the brain activity. The drug increases the production of dopamine and norepinephrine hormones in the brain thus leading to increased attention and thinking (Faraone, 2013). A dosage of 5mg is recommended for the start, and then it can be increased with monitoring if there is no improvement of symptoms.

Referral with Rationale

The patient will return to the hospital psychiatric clinic after three weeks for a checkup. The period is enough for monitoring of the child and also for possible adjustment of the medication. During the three weeks, the parents and teachers will observe the behavior of the child for improvement. Behavior therapy is recommended for the child to improve his concentration and coping with daily activities like schooling and eating.

Therapy with Rationales

Behavior therapy is a treatment plan that is used to improve the child’s behavior, self-esteem, and self-control (Wheeler, 2014). The therapy involves the use of rewards to encourage the child in the performance of activities. The major focus of behavior therapy is to encourage the child in doing activities that are difficult. The parents and teachers at school use incentives to prevent the child from being distracted. Identification of the behaviors to encourage the child is made by the parents, and together with pharmacological intervention, the symptoms are improved. The therapists usually visit the parents to equip them with skills on how to practice behavior therapy.

Legal and Ethical implications of Counseling

Medical ethics are used universally to guide the nature of the relationship between the patient and the client. The health practitioners use the ethical principles of autonomy, beneficence, nonmaleficence, and justice in making decisions about their care to the patients (Kaplan, 2014). Informed consent is a consideration during therapy sessions which ensures that patients are fully aware of the benefits and risks involved in treatment. The patients must be given options for the treatment and if the client is incapacitated the next of kin is informed. Confidentiality is a primary care consideration that involves protection of the patient’s information at all costs. Information should be given to the significant others with permission from the patient.

The healthcare providers are kept updated with the legal and ethical considerations in the provision of care to avoid any complications that may arise. As much as the physicians help the patients to cope with the illness, boundaries must exist between the client and the healthcare provider. Protection and safety of the patient’s information is a legal consideration. According to HIPAA, the patient’s information should remain within the healthcare settings for security purposes (Kaplan, 2014). Disclosure of information to third parties like media should be done with consultation and proper consideration. The breach of legal duties and ethical considerations leads to involvement of the law.









Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Young, J. M., & Solomon, M. J. (2009). How to critically appraise an article. Nature Clinical Practice. Gastroenterology & Hepatology, 6(2), 82–91.

Migone, P. (2013). Psychoanalysis on the Internet: A discussion of its theoretical implications for both online and offline therapeutic technique. Psychoanalytic Psychology, 30(2), 281–299. doi:10.1037/a0031507

Kaplan, D. M. (2014). Ethical implications of a critical legal case for the counseling profession: Ward v. Wilbanks. Journal of Counseling & Development, 92(2), 142-146.

LaMothe, R. (2015). A future project of psychoanalytic psychotherapy: Revisiting the debate between classical/commitment and analytic therapies. Psychoanalytic Psychology, 32(2), 334–351. doi:10.1037/a0035982

Faraone, S. V., & Doyle, A. E. (2013). Attention-Deficit/Hyperactivity Disorder. In Emery and Rimoin’s Principles and Practice of Medical Genetics (pp. 1-8).

Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics135(4), e994-e1001.

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