week 10 case Sarah Higgins

Name: Sarah Higgins
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.

Select one of the videos in this weeks’ resources to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected.

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis.

For this Assignment, you will assess a patient in a case study who presents with a neurocognitive or neurodevelopmental disorder.

• By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
• 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.
• Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
  Incorporate the following into your responses in the template:
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest 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.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).

Solution:

Patient name: Sarah Higgins (S.H) Gender: female Age: 11 years old

CC (chief complaint):Poor concentration and attention

HPI:  S.H. an 11-year-old female is accompanied to the clinic by her mother who comes with completed attention deficit hyperactivity disorder (ADHD) questionnaires, one completed by her teacher and another by the mother. This was after a referral from her primary care provider (PCP) who sent her for assessment after noting she was not getting proper nutrition due to difficulty meal time as she has a hard time seating for meals. The mother reports that S.H. has problems concentrating in class, staying put in her seat, inattentiveness when spoken to, only paying attention to things she has an interest in (e.g. art, museum, video games), forgetfulness, inability to follow instructions, inability to complete activities, often losingher things (e.g. assignment list, bracelet, and book), easily losing attention,trouble remaining attentive on attentive, distractibility, restlessness, is often on the go, inability to remain in her seat when she should, trouble waiting her turn…………………………..