Case study 9: | Nursing

Clinical Requirement:

CaseStudy9.docx 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. 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) Training Title 48 Top of Form Bottom of Form 1010 2:51 / 8:12 Video playing Transcript Top of Form Bottom of Form 00:00:00TRANSCRIPT OF VIDEO FILE:  00:00:00______________________________________________________________________________  00:00:00BEGIN TRANSCRIPT:  00:00:00[sil.]  00:00:15OFF CAMERA Well, thank you for bringing in these completed questionnaires on attention deficit hyperactivity disorder.  00:00:25MRS. HIGGINS Yeah, you asked me to have some of her teachers fill out the forms, and so, I had two, and I filled out one.  00:00:35OFF CAMERA Great, great, that's wonderful, and these look very, yep, very completely filled out. How are you today, Sarah?  00:00:40SARAH Fine, thank you.  00:00:45OFF CAMERA Is it okay if I ask you some of the questions about how well you pay attention in school?  00:00:50SARAH Uh-huh.  00:00:55MRS. HIGGINS Sarah, use full words.  00:00:55SARAH Yes, sir.  00:00:55OFF CAMERA You are very polite. Thank you. Some people your age have difficulty being polite. You are very polite. When teachers tell you assignments in school, how well do you remember what they said your assignments are?  00:01:10SARAH Not very well.  00:01:10OFF CAMERA Mm-hmm.  00:01:10SARAH They have to write her down a list.  00:01:15OFF CAMERA Okay. Does that list help?  00:01:20SARAH Sometimes I lose the list.  00:01:20OFF CAMERA Oh, do you forget where you put the list of assignments?  00:01:25SARAH Uh-huh. I mean, yes, I forget.  00:01:25OFF CAMERA Does that happen every time or sometimes or not very much?  00:01:30SARAH It happens sometimes.  00:01:35MRS. HIGGINS Actually, every day.  00:01:35OFF CAMERA Okay. Do you think maybe your mom is right about that, that you forget your assignment list almost every day?  00:01:45SARAH Yes.  00:01:45MRS. HIGGINS Yeah, they have to leave me a list on my cell phone.  00:01:50OFF CAMERA Oh, okay. How long has this been a problem?  00:01:55MRS. HIGGINS Pretty much since she started school, kindergarten.  00:02:00OFF CAMERA Uh-huh, let's see what else is on this list. How well do you sit still in your chair at school?  00:02:10SARAH Not very well.  00:02:10OFF CAMERA Uh-huh, do you fidget?  00:02:10SARAH (chuckles) Yes.  00:02:10OFF CAMERA Do you get in trouble for fidgeting or getting out of your chair?  00:02:15SARAH Sometimes.  00:02:20OFF CAMERA Okay, and if you're reading from a book or a paper, can you sit still then and read?  00:02:25SARAH Sometimes.  00:02:25OFF CAMERA Mm-hmm.  00:02:25MRS. HIGGINS If she really, really likes it, she'll last about five minutes or so.  00:02:30OFF CAMERA Do you remember what you read? Sarah, do you remember what you read?  00:02:40MRS. HIGGINS Sarah, he's talking to you.  00:02:45SARAH Uh.  00:02:45MRS. HIGGINS Answer him. I think this is the longest she's ever sat still.  00:02:50OFF CAMERA Oh, when you read a book, that's where I was asking, when you read a book, do you remember what you read?  00:03:00SARAH Not much.  00:03:00OFF CAMERA Mm-hmm. What if the teacher reads the book to you, do you remember what the teacher read?  00:03:05SARAH No, sir.  00:03:05OFF CAMERA Mm-hmm, you are very polite, and thank you for answering my questions. I have a few more. Is that okay if I ask you some more?  00:03:20MRS. HIGGINS Sarah, he's asking you a question, not me.  00:03:20OFF CAMERA Is that okay if I ask you some more questions?  00:03:25SARAH Yes.  00:03:25OFF CAMERA Do you lose things at home like keys or books or pencils? Just anything. Do you lose or misplace things you need?  00:03:35SARAH I lost my geography book yesterday.  00:03:35OFF CAMERA Mm-hmm, did you find it?  00:03:40MRS. HIGGINS I think she left it on the bus. The bus driver is very nice, and we put her name in the book, so we think we'll get it back.  00:03:45OFF CAMERA Well, that's good.  00:03:50SARAH I lost my bracelet, too.  00:03:50OFF CAMERA Was that a bracelet you like?  00:03:55SARAH Mimi gave it to me.  00:03:55MRS. HIGGINS My mother.  00:03:55SARAH My grandmother.  00:04:00OFF CAMERA Where do you think you lost it?  00:04:00SARAH On a trip, maybe in the bathroom at the restaurant.  00:04:05MRS. HIGGINS Yeah, we think she took it off to wash her hands.  00:04:05OFF CAMERA Sarah, do you love that bracelet?  00:04:10SARAH Lots.  00:04:10OFF CAMERA Mm-hmm, so then that was sad for you?  00:04:15SARAH Uh-huh, I mean, yes, it was sad.  00:04:15OFF CAMERA Do you ever have problems losing your temper?  00:04:20SARAH Sometimes.  00:04:20OFF CAMERA Mm-hmm, what is something at school that makes you angry?  00:04:25SARAH When the teachers say they asked me to do something, and I didn't hear them.  00:04:30OFF CAMERA Mm-hmm, do you daydream in school sometimes?  00:04:35SARAH Yes.  00:04:35OFF CAMERA What do you daydream about?  00:04:35SARAH Going home and playing with Conley.  00:04:40MRS. HIGGINS That's her dog.  00:04:40OFF CAMERA Oh, so you think about good times?  00:04:45SARAH Yes.  00:04:45OFF CAMERA Do you ever think about bad times, too, when you daydream?  00:04:50SARAH Sometimes.  00:04:50OFF CAMERA Mm-hmm, what sorts of bad times?  00:04:50SARAH Missing Mom.  00:04:55MRS. HIGGINS Yeah, we're separated right now, and we're split up, but Mom's working on us being back together real soon.  00:05:05OFF CAMERA Good, any time, Sarah, thinking about anyone, way anyone has hurt you or someone did something bad to you that they wish they didn't do?  00:05:15SARAH No, May Ann hit me one time at school, though.  00:05:20OFF CAMERA Mm-hmm, do you daydream about her hitting you?  00:05:25SARAH No.  00:05:25OFF CAMERA Oh, when you do your homework or classwork, do you make mistakes?  00:05:30SARAH Lots.  00:05:30OFF CAMERA Mm-hmm, is that pretty frustrating?  00:05:30SARAH Yes, 'cause I try to do it right.  00:05:35OFF CAMERA Mm-hmm, that must not feel good.  00:05:35SARAH It doesn't feel good.  00:05:40OFF CAMERA What are some of the questions I asked you today?  00:05:40SARAH Uh, about my dog?  00:05:45OFF CAMERA Yeah, okay. Anything else I asked you today?  00:05:50SARAH Uh, I don't know.  00:05:50OFF CAMERA Mm-hmm, were you just thinking about something else?  00:05:55SARAH I guess so.  00:05:55OFF CAMERA What were you thinking about just then?  00:05:55SARAH Your picture on the wall.  00:06:00OFF CAMERA Ah, do you like that picture?  00:06:00MRS. HIGGINS Sarah loves art, and she loves museums.  00:06:05OFF CAMERA Uh-huh, do you stand and look at the paintings for a long time?  00:06:10MRS. HIGGINS No, she runs from painting to painting, three or four times.  00:06:15OFF CAMERA Oh, let's see. I see in this form from your teachers that sometimes you have trouble waiting your turn, and yet, you are very polite today.  00:06:25MRS. HIGGINS Yeah, she's very polite, but in groups, she has a little bit more difficulty.  00:06:30OFF CAMERA Uh-huh, is it difficult to sit still?  00:06:35MRS. HIGGINS Answer his question.  00:06:40OFF CAMERA Mm-hmm, we've been sitting still a pretty long time.  00:06:40MRS. HIGGINS Yeah, this is the longest that I've seen her sit still.  00:06:45OFF CAMERA Uh-huh, do you play video games?  00:06:45MRS. HIGGINS Yeah, she likes her video games. She can stay on those for long periods.  00:06:50OFF CAMERA Uh-huh, is that right, Sarah? Is that right, Sarah?  00:06:55SARAH Is what right?  00:07:00OFF CAMERA That you can play a video game for a long time. Do you get injured much?  00:07:05SARAH Sometimes.  00:07:05OFF CAMERA Mm-hmm.  00:07:10MRS. HIGGINS Not so much now. When she was younger. We couldn't even take her to the zoo. She used to stick her hand inside of the bars where the animals could bite her.  00:07:20OFF CAMERA Oh.  00:07:20MRS. HIGGINS And she was this little thing, and she would jump up on the walls, and she even jumped in a pool before she learned how to swim, and that, that really scared us.  00:07:30OFF CAMERA Is that something that doesn't happen so much now?  00:07:35MRS. HIGGINS No, thank God.  00:07:35OFF CAMERA So, Sarah, from what your mom told me, and what these teachers listed on these forms, it sounds like everyone is in agreement that you have some kind of trouble paying attention and with remembering things and about losing things and some other problems. Do you think you'd like help with all of that?  00:07:55SARAH I guess so.  00:08:00MRS. HIGGINS Yes, we would.  00:08:05[sil.]  00:08:05END TRANSCRIPT  image1.wmf