Sample: Mental Health Evaluation
Written by: Seshu Pisipati
Typed by: Connie Chang
Demographic
Ten year old Hispanic girl lives with parents and has just started grade 5 at Uno
Elementary Charter School. She was referred by her primary doctor (Dr. Name). She
has been living at same address since birth. Patient comes from a strong Catholic
background.
History of Present Illness:
(Most of the history obtained from mother and is very reliable. )
Ten year old Hispanic girl who appears well groomed with good hygiene,
cooperative with some guarding presents with difficulty doing homework. Mother
explains she has hard time focusing, concentrating, very easily distracted, gets
extremely angry, agitated, tense and anxious (sweating palms) with all symptoms
mostly seen during studying. Patient feels she is not able to write at the same pace
as other students. She can hear well but writing is extremely slow. Homework that
should typically take 1-2 hours takes her 5-6 hours to do. School curriculum is
vigorous and grades are good. She has difficulty memorizing information and tends
to be forgetful, although not misplacing items. Being organized, careful and having a
schedule helps with her anxiety. According to mother, combing hair also takes a long
time because everything has to be perfect. When asked to perform a task fast, she
gets agitated and extremely anxious. She is otherwise not impulsive or depressed, is
very respectful to others. Her high anxiety and irritability during study sessions
drain her energy and she feels very fatigued afterwards. Patient’s biggest worry if
mom is not around is not being taken care of. Patient was last seen by her primary
care physician 2 months ago.
Why has patient sought treatment now:
2 years ago school counselors wanted her to be examined by mental health services,
but the problem was taken lightly by parents. Now, the condition has worsened.
Past Medical History
No past medical or surgical history. Patient has seasonal allergies.
Current Medications:
None
Substance Abuse:
None
Psychiatric History:
None
Trauma Assessment:
No physical or sexual abuse
Social History
Patient lives with parents, mom 44 and dad 45. She has three siblings of which 2
brothers, 14 and 15 years of age are adopted, and a 6 year old biological sister. They
are a close knit family with passive outlook, good relationships between siblings.
She has 2 good friends at school but there have been episodes of bullying at school
that have deeply hurt her. Patient is goal oriented and has plans to help sick animals.
Her three wishes are to reduce her anger, get smarter and have a dog in her life. She
comes from a strong Catholic home, where passive outlook on life is encouraged.
Parents are heavily involved in school activities. So far child has not had any legal
problems.
Family History
Mother had similar experiences as a child. Patient’s cousins from maternal side have
ADHD. No substance abuse in family. Not aware of father’s family history.
Mental Status Exam
Ten year old Hispanic girl who appears well groomed with good hygiene,
cooperative with some guarding.She is alert and oriented to time, place, person
with good memory . She is somewhat anxious but affect display appropriate. Her
speech is relevant, coherent, fluent and goal directed with normal rate and volume.
She has no experiences of hallucinations, or illusions. Her thought process is
tangential. She has no thoughts of delusions, paranoia, suicidal or homicidal
ideations. Her ability to write, calculate and general intellect are below average. Her
insight is limited and judgment is fair, with good impulse control. Patient is not
maintaining eye contact.
Diagnostic Impression
Axis I: working diagnosis of ADHD. Need to rule out generalized anxiety disorder,
general medical condition, conduct disorder and oppositional defiant disorder.
Axis II: possible dependent personality on mother
Axis III: myopia/ Need to rule out general medical conditions
Axis IV: mild to moderate social issues
Axis V: GAF 55
Assessment
Ten year old Hispanic girl presents with mother for trouble doing homework.
Problem was first noticed 2 years ago but started getting worse lately. She is not
able to focus, concentrate, very easily distracted and gets angry, agitated and
anxious under conditions of stress. She is having trouble with being bullied at school
and is being shunned by peers. Attention deficit hyperactive disorder runs in the
family from maternal side. She fits into the criteria of ADHD but other conditions
like generalized anxiety disorder, general medical conditions, conduct and
oppositional defiant disorders, age appropriate behavior, response to
environmental problems, mental retardation autism and mood disorders are to be
ruled out. Her precipitating issues are school work and any type of stress. Her
perputiating issues are the unaddressed problems.
Ruling out differential Diagnosis
Generalized anxiety disorder: this is a good possibility because she has anxiety over
small things like imperfections over hair combing
Response to environmental problems: her response is beyond normal to difficulties
in homework. She gets extremely tense to the point where she is giving mean stares
to mother, palms get sweaty, all her muscles get rigid
Age appropriate behavior: most likely not since significant anxiety, agitation with
age appropriate tasks of doing homework
Conduct/ oppositional defiant disorders: are highly unlikely since child has no legal
problems, is very respectful to others and authority figures and is under the age of
18(rule out conduct disorder).
Mental retardation: need to do IQ testing
Autism: highly unlikely due to no anti social behavior, communication problems, no
significant inflexibility to demands of life.
General Medical Condition: need to be ruled out by primary doctor
Mood disorder: patient has no symptoms of depression and bipolar disorder
Management/ Treatment Plan
IQ testing
Outpatient psychotherapy
Cognitive behavioral therapy
 emphasis on stress coping mechanisms, self-esteem issues, assertive
training
Social therapy
 emphasis on support group for bullying; parents education
Cultural: work with parents to overcome stigma
Spiritual: continue with religion to instill solid values, give a purpose to life
Labs: CBC, CMP, TSH, lead, HbA1C, EKG, UA-drug test
Consider psychostimulants