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3 pages/≈1650 words
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Biological & Biomedical Sciences
Other (Not Listed)
English (U.S.)
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Symptom Analysis Evaluation Biological & Biomedical Essay (Other (Not Listed) Sample)


Symptom Analysis Evaluation #2
Chief complaint: “I don’t apologize and I don’t talk about my feelings.”
HPI: Dan is a 15 years old African American male who was admitted into the inpatient unit under temporary
detention order by the court. Dan was admitted for psychiatric evaluation due to physical aggression towards
staff members at the group home where he’s been staying for about four months. Dan said that the staff
member was “running his mouth.” Before the attack, Dan had told the staff member to shut up when asked
to clean his room. The staff then confronted him for being disrespectful, but Dan began to raise his voice,
attacked the staff member, and broke a piece of furniture. He expressed no remorse about the injuries he
inflicted on the staff. Admits to the history of bad dreams and nightmares, denies obsessive thoughts, denies
hallucinations, and paranoia but reports that he sometimes thinks he hears his name yelled out when no one
is around. He denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue.
Psychiatric History:Preschool- behavioral problems with aggression towards peers, a problem with speech
articulation, fell behind in the academics; elementary school- bedwetting, aggression, defiance, bossiness, poor
sleep. Saw psychiatrist for the first time in elementary school and was tried on a high dose of stimulant. He
was also prescribed clonidine and imipramine around the same time. In middle school, he was charged with
assault after attacking a peer as a result of jealous rage and referred for anger management. Past psychiatric
medication trials- Dextroamphetamine/amphetamine (not helpful), clonidine and imipramine
Past Medical History: Dan has seasonal allergy.
Surgical History: No surgical history
Family Medical / Psychiatric History: Mother has undiagnosed bipolar disorder and PTSD from sexual
abuse by an uncle as a teenager, cocaine addiction, high cholesterol, and obesity. Father- Untreated bipolar
disorder, anger issues, repeated incarceration.
Social History: Lives in a group home, CPS placement due to neglect and abuse since kindergarten. Dan
took care of the younger brother for the most part due to his mother’s ongoing addiction issues, denies a
history of tobacco use and substance abuse. Dan is in 8th grade, receives extra help at school, and on
Individual Educational Plan (IEP).


Symptom Analysis Evaluation
Symptom: Identify appropriate history questions to be asked of your patient to discriminate critical characteristics or attributes about the above presenting complaint. Incorporate COLDSPA (Characteristics, Onset, Lingering, Duration, Stressors, Precipitating factors/triggers, Alleviating factors).
Hallucination assessment
Have you ever heard unrealistic sounds, or voices, Does directly address you or someone else? How do you hear them? What is the content of the voice? Do they comment and judge your actions? Does it influence you to harm any other person? have ever had any stage smell or tastes?
Thought assessment
Have you ever had thought insertion in terms of something else putting you on running thoughts? have you ever had a thought broadcast or loud thinking? Have you ever felt some thought controlling you more than you control it? have you ever thought of people on social media, TV or Radio like they are addressing you directly? Do you feel someone is spying on you? Do you feel that someone is watching you? How did it start
Drug use
Do you take any drug? At what age did you start taking the drug? Can you live without the drug? Which case initiates you into the drugs abuse?

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