Chief complaint: “They make me mad.”
HPI: Michelle is an 11 Years old Caucasian female who was admitted into inpatient crisis stabilization unit. Patient was accompanied by mother who reports that patient has been having increase aggressive behaviors such as pushing kicking, punching the walls, breaking silver wares and inflicting injuries on peers at school. Michelle gets easily overwhelmed, aggravated and angered. Michelle’s mother reports that symptoms has worsened in the past 3 months and not sure what to do. Michelle’s behavior has caused a lot of issues in her parent’s marriage and increased anxiety within the family. Michelle no longer has friends at school and home due to her aggression. She denies visual, auditory and tactile hallucinations, denies paranoia and substance abuse. Michelle and mother denies head injury, sudden weight loss, excessive sweats, hair loss, and chronic fatigue.
Psychiatric History: Michelle has never been psychiatrically hospitalized but has seen a psychiatric provider two years prior. Michelle’s mother states that Michelle was once diagnosed Oppositional Defiant Disorder and ADHD. Current provider diagnosed patient with ADHD and mood disorder. Michelle is currently taking prescribed stimulant drug along with low dose Risperdal. Michelle has no history of suicide attempts or homicide.
Past Medical History: Michelle is in good physical health with no medical hospitalizations.
Surgical History: None
Family Medical History: Mother- Alive, age 32, Depression. Father- Alive, 38, high cholesterol, Brother- Alive, healthy, 7 years old. Sister- Alive, Eczema, 2 years old
Social History: Michelle lives in a townhome with parents and siblings. She was removed from the soccer team last month after two weeks of enrollment due to behavioral issues. Michelle states all her friends are no longer taking to her because they feel she’s mean. Denies history of tobacco use. Denies sexual activity but started menses at age 9.
Educational/Occupational History: Michelle is in middle school and not doing well. Complete two years of college.
Developmental/Family History– Michelle is the oldest of three children. She was born and raised in an urban Southern state. Michelle’s mother denies developmental issues. Michelle does not have good relationship with siblings. Mother is a stay home mom while father works for an IT company and work long hours.
Review of Systems: 10-system ROS negative except symptoms noted in HPI.
Medications: Adderall 10mg q 8am and q 4pm, Risperdal 0.5mg qhs
Vital Signs: BP 108/60 HR 72bpm, T 97.9F, RR 16/min Weight 96 lbs. without significant recent changes.
Review the above case study and complete the CAE Sections below. Remember to use appropriate APA in-text citations and reference list.
A. Health History/History of Present Illness. Identify history questions to be obtained to discriminate critical characteristics of the presenting chief complaint (symptom).
B. Differential Diagnosis: Delineate 4 differential diagnosis that could support the chief complaint and HPI. Include DSM-5 diagnostic code for each of the differential diagnosis.
C. Mental Status Examination: Delineate mental status exam findings that would be associated with each listed differential diagnosis.
D. Etiology: Delineate the etiology of each of the 4 differential diagnosis. Include psychosocial factors and past experiences that may be contributing to current symptoms.
E. Diagnostic Screening Tools: Delineate what diagnostic screening tools would be appropriate for each of the 4 differential diagnosis.
F. Analysis: Delineate your final assessment along with rationale.
G. Treatment Plan: Delineate appropriate treatment plan which should include psychological therapeutic modalities and the focus, social interventions (support or self- help groups, mobilization of family resources, vocational rehabilitation, financial planning) and identification of strengths.
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