Week (enter week #): Comprehensive Psychiatric Evaluation and Case Presentation for Adolescent
Male with Disruptive Mood Dysregulation Disorder in Foster Care
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6645: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
, PRAC 6645 Comprehensive Psychiatric Evaluation Template
Subjective:
CC (chief complaint): “I am here because my foster mother lied about me being
aggressive towards her.”
HPI:
I.M. is a 13-year-old Caucasian male presenting for psychotherapeutic evaluation due to
reported aggression and behavioral issues. He is currently prescribed multiple
medications including Remeron, Adderall XR, Clonidine, Melatonin, Ziprasidone, and
Prozac. He was referred by Lehigh CYS for evaluation and treatment.
The patient denies issues with aggression but admits he “can get angry.” However, his
CYS guardian reports a long history of aggression towards adults and peers. I.M. has a
documented history of fire setting, physical aggression, and self-harming behaviors. His
foster parents recently gave 30-day notice due to aggression.
I.M. denies current mood symptoms, anxiety, hallucinations, or delusions. He reports no
suicidal or homicidal ideation. Sleep and appetite appear stable on current medications.
Past Psychiatric History:
General Statement: The patient entered psychiatric treatment at an unknown
age, with a history of multiple placements and interventions due to behavioral
issues.
Caregivers (if applicable): Currently in CYS custody, placed with foster parents
since 2019.
Hospitalizations: Multiple inpatient hospitalizations reported, but specific details
are unclear. History of self-harm including putting a plastic bag over his head and
attempting to jump out of a moving vehicle.
Medication trials:
1. Remeron 15 mg at bedtime
2. Adderall XR 10 mg daily
3. Clonidine 0.05 mg three times daily
4. Melatonin 9 mg at bedtime
5. Ziprasidone 40 mg twice daily
6. Prozac 40 mg daily
© 2022 Walden University Page 2 of 7
Male with Disruptive Mood Dysregulation Disorder in Foster Care
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6645: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
, PRAC 6645 Comprehensive Psychiatric Evaluation Template
Subjective:
CC (chief complaint): “I am here because my foster mother lied about me being
aggressive towards her.”
HPI:
I.M. is a 13-year-old Caucasian male presenting for psychotherapeutic evaluation due to
reported aggression and behavioral issues. He is currently prescribed multiple
medications including Remeron, Adderall XR, Clonidine, Melatonin, Ziprasidone, and
Prozac. He was referred by Lehigh CYS for evaluation and treatment.
The patient denies issues with aggression but admits he “can get angry.” However, his
CYS guardian reports a long history of aggression towards adults and peers. I.M. has a
documented history of fire setting, physical aggression, and self-harming behaviors. His
foster parents recently gave 30-day notice due to aggression.
I.M. denies current mood symptoms, anxiety, hallucinations, or delusions. He reports no
suicidal or homicidal ideation. Sleep and appetite appear stable on current medications.
Past Psychiatric History:
General Statement: The patient entered psychiatric treatment at an unknown
age, with a history of multiple placements and interventions due to behavioral
issues.
Caregivers (if applicable): Currently in CYS custody, placed with foster parents
since 2019.
Hospitalizations: Multiple inpatient hospitalizations reported, but specific details
are unclear. History of self-harm including putting a plastic bag over his head and
attempting to jump out of a moving vehicle.
Medication trials:
1. Remeron 15 mg at bedtime
2. Adderall XR 10 mg daily
3. Clonidine 0.05 mg three times daily
4. Melatonin 9 mg at bedtime
5. Ziprasidone 40 mg twice daily
6. Prozac 40 mg daily
© 2022 Walden University Page 2 of 7
