Clinical Log for Child with Pyschiatric Disorder Essay

CLINICAL LOG 

Client Information: Name: Jay Smith

                                 Initials: J.S

Age: 8yo

Gender: Male

Ethnicity: Caucasian

CC: “I have been restless and he gets fatigued very easily. I also have poor concentration, irritability and excessive worry.” Clinical Log for Child with Pyschiatric Disorder Essay.

History of Present Illness:

A 8 years old boy is brought to the office by her mother who reports that he has been getting irritated easily and he is restless most times. She adds that the child has poor concentration in his activities and studies, he gets fatigued easily and he has excessive worry She says that the child has never been diagnosed with depression and he has never had traumatic events in the past. Mother states that the child has been having excessive worry about his academics, about the safety of his family members especially when they stay out late. She also says that the child is excessively worried about earthquakes and being punctual.

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Past psychiatric history:

No past psychiatric hospitalization, client denies any thoughts of suicidal/homicidal.

Current Medications: None 

Allergies: No Known Drug Allergies 

Psychosocial History:

J.S is a fourth grader who lives with her both parents in North Carolina. He has two sisters and a brother.

Family History of Psychiatric Illness:

His older sister who is eighteen was diagnosed with depression when she was ten. No history of smoking, alcohol consumption or illicit drug use. Clinical Log for Child with Pyschiatric Disorder Essay.

General Assessment: Patient looks tired and tried to be very organized with his toys. He alos keeps stealing glances at his mother as he plays.

Mental Status Examination:

Patient is restless and looks fatigued. His concentration is unusual and he gets irritated easily and is excessively worried about catastrophic events like earthquakes, her parent’s safety and arrangement of his toys.

Diagnosis DSM-5:

F41. 1 – Generalized Anxiety Disorder: This is a disorder that is characterized by worry that is difficult to control and which interferes with day to day activities. In children, the disorder present through fatigue, irritability, sleeping problems, trembling, nervousness, nausea sweating, excess worry about school performance and sports, safety of family members, catastrophic events like earthquakes, and punctuality (Cho, Przeworski & Newman, 2019). Patient presented with most of these symptoms which his mother said have been persistent for the past 6 months. Patient also met all the meets clinical criteria for GAD as he presents with at least three of the possible six required to make a diagnosis. Other lab tests also confirmed generalized anxiety disorder as the primary diagnosis.

Plan of treatment:

The recommended first line treatment for children with generalized anxiety disorder is cognitive behavioral therapy and non drug therapy such as psycho-education and anxiety management training (Bandelow, Michaelis, & Wedekind, 2017). Clinical Log for Child with Pyschiatric Disorder Essay. These therapies are given before medication for mild to moderate case. 

References

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93.

Cho, S., Przeworski, A., & Newman, M. G. (2019). Pediatric generalized anxiety disorder. In Pediatric Anxiety Disorders (pp. 251-275). Academic Press.

CLINICAL LOG 

Client Information: (Name: Initials, Age, Gender, and Ethnicity) 

CC: 

History of Present Illness:

Past psychiatric history:

Current Medications: 

Allergies: 

Psychosocial History:

Family History of Psychiatric Illness:

Mental Status Examination:

Diagnosis DSM-5:

Plan of treatment:

Fill in the clinical log for a child with an adolescent psychiatric disorder  

Client Information: (Name: Initials, Age, Gender: and Ethnicity) 

CC: “M., unable to concentrate, Poor performance in school, anxiety “ 

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History of Present Illness: Client mother states that she started noticing some behavioral changes 2 years ago; patient inability to concentrate, anxiety, agitation, inattentiveness from schoolteacher’s report. School teacher called to report client behavior of constantly moving in class, from one desk to the other and not paying attention. Lately, patient has been having increase anxiety especially when logging into the school system for schoolwork. Mom also stated that he has not been diagnose with ADHD and has being having trouble concentrating. In the past patient has managed symptoms by listening to music, being active, taking walks, relaxation and reading books.Clinical Log for Child with Pyschiatric Disorder Essay.  Since the locked down, his symptoms have increased. School grades have dropped, and client had since quit school as well due to increased anxiety.

Past psychiatric history: Client was diagnosed of ADHD and anxiety and autism spectrum disorder (ASD) disorder when he was 6year old, parent declined medication and was referred behavioral therapy at age 7, which was not effective. Client was started on Adderall 5mg 3months ago, no adverse effect reported, client has tolerated medication well. No past psychiatric hospitalization, client denies any thoughts of suicidal/homicidal.

Current Medications: Adderall 5mg by mouth daily and client is compliant with medication

Allergies: No allergy reported.

Psychosocial History: M.O. is the only biological child, he lives with mother, and stepfather, he has a 15yr old stepbrother that live with them. Patient is in 3^rd grade but is current out of school because of his increase anxiety. Poor social interaction with siblings, no special education or program.

Family History of Psychiatric Illness: Mother has no psychiatric illness, father has ADHD.

Smoker: None, History of alcohol, marijuana, meth use/abuse:  None

General Assessment: Client is alert/oriented x 3, mood euthymic, attention and concentration are poor, no evidence of any abnormal movements. Client mother reports that client sleep is fair but not for long, 5-6 hours at night, no evidence of abuse, hygiene is good.

Mental Status Examination: Alert/oriented all aspect, client understands what is going on, speech muttered, poor volume of voice, mood euthymic, thoughts are organized, no evidence of mania or delusion. Speech Fluent and normal Aphasia, client focus during the interview is poor with poor interaction. Patient denies thoughts of hurting self or others. Clinical Log for Child with Pyschiatric Disorder Essay. Insight is fair as evidenced by understanding of illness and need to participate in treatment. Client is Alert Orientation to all aspect. His attention span is limited as evidenced by client able to follow short conversation. Immediate Intact as evidenced by ability to answer questions. Recent Memory intact as evidenced by ability to recall details of when he gets his medication. Client can tell story during the interview, judgment is fair as evidenced by interview, client is able to associations Well-related.

Diagnosis DSM-5:

(F84.0) Autism spectrum disorder

(F90.9) Attention-deficit hyperactivity disorder, unspecified type

(F41.9) Anxiety disorder, unspecified Subjective

Plan of treatment: Client will Continue Amphetamine-Dextroamphetamine (Adderall XR) 5mg Oral Capsule, 1 capsule (5mg) by mouth daily in the morning and Zoloft 25mg 1tab was added to client medication. Client will be followed up in 2 weeks. Clinical Log for Child with Pyschiatric Disorder Essay.