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Patients’ Differential Diagnosis

For each case you will need to provide the following information based on the written presentation of the client’s symptoms:

  1. Provide a description of each differential diagnosis you are considering for the case.
  2. Present the diagnosis you favor most and why.

 

Case 1. (sample format)

  1. Primary Diagnosis___________________________________________
    • Supportive evidence
    • Supportive evidence

 

  1. Differential Diagnosis (rule out)_________________________________
    • Supportive evidence
    • Supportive evidence
    • Supportive evidence

 

 

Case #1

 

Identifying Information

Jan is a 22 year old, Caucasian, female living with her mother and grandmother. She does not work and is currently taking a break from school due to stress and anxiety.

 

Chief Complaint

“I want to live normally…with reduced level of anxiety and on minimal medication”.

 

Presenting Problem

Client reports worrying about a number of things including: going back to school, making money to move out of her mother’s house, getting her car fixed so she can apply for jobs, getting off of her medication. Jan states, “I can’t sleep with all of this stuff in my head…I need to get it out!” She reports a general state of irritability throughout the day. Jan admits to smoking marijuana occasionally to help alleviate the stress, “I only smoke when it gets really bad”. Jan hasn’t smoked in a month in order to pass a urine screen should she find work.

 

Phobia of vomit/ throwing up – Jan was the first person to discover her aunt after she overdosed on heroin and remembers seeing her lying in a pool of vomit. Jan was close to her aunt and worries about her own addiction.

 

Psychosocial History

Previously a client at Yale New Haven Hospital for panic attacks. The client has a history of feeling agitation, anxiety and panic attacks (4 in the past 6 months). Jan had her first panic attack during a biology midterm, “I thought I was having a heart attack”. Jan has a few close friends but “no one I can really rely on”. Jan has questionable boundaries with her mother and they fight constantly. Jan reports, “she tells me everything and I tell her everything”. One of the main things they fight about is that Jan wants to go back to school but her mother doesn’t think she’s ready. In the past, she threatened to stab her mother with a knife.

 

FamilyHistory:

Cousins – history of anger issues; grandfather – anxiety; aunt – drug addiction – passed away from overdose 2011 while living in client’s mother’s home

 

Mental Status Exam

  • Appearance: smelled of cigarette smoke, hair died blue and pulled back in a messy ponytail. Loose fitting clothes and a t-shirt with a smiley face smoking pot.
  • Attitude: cooperative,
  • Motor Activity: seems restless, shifting in seat, ringing hands, eye darting.
  • Mood / Affect: seems anxious as evidenced by darting eye contact, pressured speech. Client reports feeling “stressed out”.
  • Speech: pressured, verbose, circumstantial. Volume was loud at times when talking about stressful relationship with her mother.
  • She denies audiovisual hallucinations.
  • She denies Suicidal ideations/Homicidal Ideations

 

 

Medical History

  • Klonopin 1 mg tablet: 1.5-tablet/by mouth / DAILY (Prescribed on: 07/23/2015 05:49 PM) (Dispense: 45 Tablet) NuvaRing 0.12 mg -0.015 mg/24 hr vaginal: 1-unit/in the vagina / as directed (Prescribed on: 06/08/2015 10:01 PM) (Dispense: 1 Milliliter)
  • Previously on: Lamictal 100 mg tablet: 1-tablet/by mouth / DAILY (Prescribed on: 06/06/2015 12:50 PM) (Dispense: 30 Tablet, Refills: 2)
  • Zoloft 50 mg tablet: 3-tablet/by mouth / DAILY (Prescribed on: 06/06/2015 12:50 PM) (Dispense: 90 Tablet, Refills: 2)

 

 

 

Case #2

Identifying Information:

Rosemary is a 66-year-old woman, Latina, Spanish speaker, who came to the Bridgeport area in the late 60s at the age of 18. She currently lives in a rental house with her daughter, and three grandsons.

Chief complaint:

Rosemary stated that, “my family has been driving me crazy…they think I need counseling”. Client admits to having difficulty sleeping and nightmares. Rosemary’s daughter thinks she needs to talk about what happened.

Presenting Problem:

Rosemary was advised by to come in for services several months ago, but waited before actually making the appointment. Approx 6 months ago,she was assaulted at gun-pointas she was walking home from church. The strange man stole her phone, pushed her to the ground and then ran off. As a result, Rosemary suffered a hip fracture and bruising on her arm and legs. After the attack, she immediately felt her life shift because “I couldn’t predict my own death”. Client reports to having premonitions about death and believes “ I know who will die”. Client feels safest at home and rarely takes the opportunity to go out. She sleeps only a few hours at night. Client reports feeling nervous and is currently struggling to make her appointments to physical therapy because of the stress of leaving home. Client has ceased to attend church and sends her daughter out for groceries.

Psychosocial History:

Rosemary is an expressive woman, and she looks older than her age of sixty-six years. She has long black hair, which was tied back and she was a little disheveled but comfortably dressed. She was cooperative but anxious about sharing her personal history. Client is single; however, she lived with her partner for 17 years, and she had 3 children. One of them was murdered in 1990 here in Bridgeport, when he was 21 years-old. Client presented herself a little guarded and suspicious, but she wanted to engage in counseling services. She reported no history of hospitalization, no voices commanding her to hurt herself, but admits to having suicidal ideations in the last 2 weeks (to jump in front of a metro). Rosemary does not currently work, but served as a laundry attendant for 10 years.

Medical History

Rosemary is taking Sertraline HCL 100mg, and Viibrid 20 mg because she has been feeling very nervous.

 

Mental Status:

  • Client appearance was a little disheveled, but she was comfortably dressed.
  • She presented herself a little guarded and suspicious.
  • Client’s mood was “nervous”; affect anxious
  • Speech was clear and sometimes spontaneous (talkative).
  • Client’s thoughts were lucid, intact, and oriented.
  • She had impaired memory as evidenced by forgetting events both in the recent history and long-term history of her life.

 

 

 

Case #3

Identifying Information

Alice is 6 y/o biracial female who lives with mother, father, 14 y/o sister, and 1.5 y/o sister. Her father is African American and Mother is Caucasian.

Chief Complaint

Alice was presented by her parents for evaluation for issues with impulse control and inappropriate sexual behavior at school, at home and at her aunt’s house.

Presenting Problem

Two weeks ago, Client A was caught engaging in genital touching with another girl in the bathroom at school. When confronted about the issue, Alice said that she “learned it from her classmates in school”. About a month ago, Alice and her older female cousins were caught watching pornography on a laptop. Alice has a history of hypersexual behavior and as a result, is not allowed to visit her cousin’s house unsupervised. Alice denies any inappropriate sexual touching by strangers or family members.

Psychosocial History

Alice is a lively six y/o female with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). Her parents report that various friends and family members “crash” at their home from time-to-time. Currently her father’s cousin is living in the household. Client’s mother works full time and father is unemployed and stays home with the children. Dad has expressed a desire to go back to work but Mom insists that he stay home with the kids. Dad currently collects disability for a car related accident. Mom admits to several extra-marital affairs.

Alice attends a public school and is currently in kindergarten. She reports having just two friends in her class. Alice maintains satisfactory marks on her schoolwork but is often in trouble with the teacher for breaking class rules. Her older sister attends a behavioral school elsewhere. Alice reports having a good relationship with her sister except, “we fight about sharing a room”.

Family History

A history of borderline personality disorder is present in the maternal grandmother and the mother of Alice. Thus increasing the likelihood of multigenerational childhood trauma and possible sexual abuse.

Alice’s older sister has as diagnosis of bipolar d/o and has been hospitalized several times during manic episodes. The last time it happened, she stripped naked in the therapist’s office and climbed on the furniture. Her father experiences chronic pain but receives adequate pain relief through medication and physical therapy.

Mental Status Exam

  • Appearance: well-groomed, clean, normal weight
  • Behavior: hyperactive, cooperative, good eye contact, tried to hug and kiss the counselor during our first meeting. Also tried to sit on the secretary’s lap while her mother was making a follow-up appointment
  • Speech: fluent, clear, normal volume with spells of high volume
  • Perception: no hallucinations
  • Cognition: oriented to situation, time, place, and person; alert, memory intact, intelligence: average
  • Mood: euthymic
  • Affect: pleasant, happy, euphoric, non-labile, and congruent to mood

Current Medications

Client is currently taking Focalin XR 10mg AM and 5mg PM as well as Guanfacine 1mg PM.

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Category: Sample Questions