Symptom Analysis Evaluation #2: Dan is a 15 years old African American male who was admitted into the inpatient unit under temporary detention order by the court..
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 heâ€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).
Family History- Dan was physically and emotionally abused by his father. Mother has substance abuse and was never home when the patient lived at home.
Review of Systems: 10-system ROS negative except symptoms noted in HPI.
Vital Signs: BP 108/60 HR 62bpm, T 98.9F, RR 12/min Weight 140lbs without significant recent changes.
Symptom Analysis Evaluation Instructions
Review the case study assignment for this module and complete the SAE Sections using the template. The first SAE assignment is an individual assignment in week two. The second SAE is a group assignment in week four. Remember to use at least five references and appropriate APA in-text citations and reference lists. SAE is due by Sunday at 11:59 pm (ET).
- Health History/History of Present Illness: Identify history questions to be obtained to discriminate critical characteristics of the presenting chief complaint (symptom). Incorporate COLDSPA (Characteristics, Onset, Lingering, Duration, Stressors, Precipitating factors/triggers, Alleviating factors).
- Differential Diagnosis: Delineate 4 differential diagnoses that could support the chief complaint and HPI. The differential diagnosis has to support the above symptoms in relation to pertinent answers given in the history. MOST use appropriate DSM 5 diagnosis and provide rationale for each choice differential diagnosis base on the presenting case.
- Mental Status Examination: Delineate mental status exam findings would be associated with each listed differential diagnosis. Document the subjective data that the patient might have reported. Use all component of MSE listed- Appearance, Behavior, Speech, Affect, Thought process, Thought content, Insight, Judgement, Cognitive examination (level of awareness, Attention and Concentration, Memory, Orientation etc). Must support with literature and use the appropriate descriptors in each component. Avoid using “normal” or “Good” as a descriptor.
- Pathophysiology: Delineate the neurophysiology, pathophysiology and etiology of each of the 4 differential diagnoses.
- Diagnostic Testing: Delineate what diagnostic tests would you obtain to rule out medical issues that mimic each of the differential diagnosis and mental health screening tools.
- Analysis: Delineate your final assessment along with rationale. Identify the primary diagnosis from the 4 differential diagnoses and support with the DSM 5. Discuss why the other differential diagnosis are less likely for the case.
- Treatment Plan: Delineate appropriate treatment plan (pharmacotherapy and non-pharmacotherapy) for the primary diagnosis.
These assignment are due by 11:59 p.m. (ET) on Sunday of the assigned module/week.
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