Case study 9

Gender: female

Age: 11 years old

T- 97.4 P- 58 R 14 98/62 Ht 4’5 Wt 65lbs

Background: no history of treatment, developmental milestones met on time, vaccinations up to date. Sleeps 9-10hrs/night, meals are difficult as she has hard time sitting for meals, she does get proper nutrition per PCP. she has a younger brother. lives with her parents in Washington,D.C. No hx of head trauma.

Symptom Media. (Producer). (2017). Training title 48 [Video].

Use the attached Template:

A.Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS

B.In the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

C. In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form.• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

· Consider what history would be necessary to collect from this patient.

· Consider what interview questions you would need to ask this patient.

· Identify at least three possible differential diagnoses for the patient.

D.Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

E. Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

· American Psychiatric Association. (2022). Substance related and addictive disorders. In Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x16_Substance_Related_Disorders

· Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

· Chapter 3, “Neurocognitive Disorders”

· Chapter 2- sections 2.1 “Intellectual Disability”, 2.2 “Communication Disorders”, 2.3 Autism Spectrum Disorder, 2.4 Attention-Deficit Disorder, 2.5 “Specific Learning Disorder”, 2.6 “Motor Disorders”

· Chapter 26 “Level of Care”

· Chapter 29 “End-of-Life Issues and Palliative Care

Video Transcript:

Test Section Index, Episode 48 (Santa Monica, CA: Symptom Media, 2017)