PRAC 6645 Week 7 Assignment 2; Comprehensive Psychiatric Evaluation Note and Patient Case Presentation - IMPULSE-CONTROL
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Subjective:
CC (chief complaint): “Mommy says I am too much”.
HPI:
E.T is a 5-year-old Caucasian female presenting to the office with her mother and older sibling.
Her mother states that she is defiant and is always picking fights with her older sister.
E.T denies anxiety but does not seat still during the interview. She is easily distracted and sometimes answers questions inappropriately, changing topics from time to time. Her mother reports one incident of altercation over toys with another child at preschool.
Past Psychiatric History:
E.T has never been diagnosed with mental illness.
Substance Current Use and History: Denies
Family Psychiatric/Substance Use History: Illicit substance use by mother during pregnancy.
Psychosocial History:
E.T was born orange county, California to a mother addicted to illicit substances. She was adopted by her current parents at 2 yrs. old. She lives with her adopted parents and older sibling, also adopted. Her mother is a homemaker, and her father works with the county as an electrical contractor……….. Continue
