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.

Symptom Analysis Evaluation Assignment Instructions

Overview

Review the case study assignment for this module and complete the Symptom Analysis Evaluation (SAE) Sections using the template. The first SAE assignment is an individual assignment. The second SAE is a group assignment. Remember to use at least five references and appropriate APA in-text citations and reference lists.

Instructions

A. 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).

B. Differential Diagnosis: Delineate 4 differential diagnoses that could support the chief complaint and HPI. The differential diagnosis must support the above symptoms in relation to pertinent answers given in the history. Must use appropriate DSM 5 diagnosis and provide rationale for each choice differential diagnosis base on the presenting case.

C. 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.

D. Pathophysiology: Delineate the neurophysiology, pathophysiology and etiology of each of the 4 differential diagnoses.

E. 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.

F. 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.

G. Treatment Plan: Delineate appropriate treatment plan (pharmacotherapy and non-pharmacotherapy) for the primary diagnosis.

Symptom Analysis Evaluation: Adult Mental Health Case

Chief complaint: “I have horrible mood swings and I get angry easily.”

History of Present Illness: Mark is a 37-year-old Caucasian male with no prior psychiatric hospitalizations who presents to the outpatient clinic for evaluation and treatment of symptoms of mood swings. He reports a long history of mood instability that began in his early teens and has worsened throughout his twenties and thirties. Mark reports increased irritability, agitation, racing thoughts, mood swings, and chronic sleep difficulties. Mark states symptoms are present 5-6 days a week and present throughout the day. He reports using marijuana to calm down once to twice a month and drinking alcohol 3-4 cans of beer on weekends in the past three weeks. Denies bad dreams or nightmares, denies obsessive thoughts, denies hallucinations, and paranoia. Denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue.
Psychiatric History: Mark has never been hospitalized for psychiatric illness, has no history of suicide attempts, no homicide attempts, and no history of violence. However, he reports frequent thoughts of death when severely depressed in the past three months. He has never seen a psychiatric provider before this visit. He has been prescribed selective serotonin reuptake inhibitors (SSRI) by his PCP in the past for depression. Mark reports that the medication did not make much difference in treating his symptoms.
Past Medical History: Mark reports childhood asthma, depression and anxiety.
Surgical History: Tonsillectomy

Family Medical History: Mother has depression, type 2 diabetes mellitus, CKD, CVA; died of kidney failure at age 75. Father- Schizophrenia, HTN, CAD; died at age 50-years. Brother has bipolar and has alcohol problems. Sister is healthy but has “very mean attitude.”
Social History: Lives with girlfriend of one year in a rental apartment. Mark works part time at a local construction company. Girlfriend works full time at a departmental store. Denies history of tobacco use.
Family History- Mark and his brother were physically, and emotionally abused by the father as a child. He did not recall the mother stepping in to provide protection when the father was abusive. Mark has a strong relationship with his cousin who is two years younger. Mark’s sister is 20 years old and lives at mother’s house along with her two years old daughter. Brother lives with his friends.
Review of Systems: 10-system ROS negative except symptoms noted in HPI.
Medications: None
Allergies: NKDA

Vital Signs: BP 110/60 HR 65bpm, T 98.9F, RR 12/min Weight 170lbs without significant recent changes.

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