Come With Leading Question & Answer Guide (With Explanation)

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What This Question Is About

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How to Approach This Question

Focus on explaining concepts clearly and supporting them with examples.

Key Explanation

This topic involves come with leading. A strong answer should include explanation, application, and examples.

Original Question

How can I Come out with a leading diagnosis and the rationale for that diagnosis Differential diagnosis about 3 The screening tool possible to use to guide diagnosis possible treatment education to give to the patient Any other relevant information Initial Psychiatric Evaluation Name: T I Identifying information: Travis is a 20 y/o Caucasian male. Brown hair, blue eyes and RX glasses Informant: Information was obtained from direct interview with the patient and review of intake assessment. Chief complaint: “I couldn’t do well in my college. I still can’t focus or get organized.” HPI: Travis presents with a well-documented history of inattention, distraction, poor frustration tolerance and difficulty with follow through. He describes having attention and concentration issues since early childhood. He reports that from grade school to high school he did well academically and attributes this to the structure he had at home and school. He does report that his forgetfulness often frustrated his parents, especially his mom, who was upset with him for forgetting to do his chores, having a real messy room, forgetting to brush his teeth and procrastinating on big school assignment. Travis does not have a history of hyperactive or significant impulsivity. Travis notes that his first college semester was difficult because he had to structure himself. He struggled with being organized, remembering to complete assignments and staying focused on a task. He described feeling overwhelmed with the amount of work and couldn’t decide how to being a project. Therefore he would put off complex assignments until the last minute then rush through the project, which resulted in making careless mistakes, or become frustrated and giving up. Travis was demoralized after his freshman year of college and did not return for his sophomore year. Travis took a job at a local hardware school and reports that there is a lot of variety in his job, which helps him to not feel bored or frustrated like he did when working on academics. Travis reports that working full time in retail has helped him to realize that he wants to go back to college. He would like to study business. Travis does endorse being a “worry wart.” He described being worried that he isn’t as good as others and that his life isn’t “going to turn out ok” or that “something bad will happen to my family.” He reports that often he can’t get to sleep at night because the days event’s replay in his mind and he can’t seem to control these thoughts. When especially worried he experience’s nausea and tension in his neck and shoulders. He can feel irritable and “keyed up.” He has no history of mood symptoms consistent with depression or bipolar mood disorder mania/hypomania. He denied any history of psychotic symptoms. Previous psychiatric services: Medication prescribed through PCP. He has not had therapy. Previous medication trials: Strattera 40mg, which causes delayed ejaculation. Allergies: No known drug allergies, food allergies, or environmental allergies. Current medications: None Medical history: Seasonal allergies, Bilateral Myringotomy placed at 18 mo. Immunizations are reportedly up to date. No other history of major illness, surgery, hospitalization, head injury, or loss of consciousness. Growth and development: From the intake assessment: he was a planned pregnancy, mother received perinatal care, full term pregnancy with vaginally delivery. Both pregnancy and delivery were unremarkable. Developmental milestones for language acquisition, fine and gross motor skills and social development are on time. Family history: Travis is one of three children born to his biological parents. There is a maternal family history of anxiety. His mother is being treated for anxiety with Lexapro. There is a paternal great uncle was alcoholic and died of cirrhosis. There are two paternal cousins diagnosed with ADHD. There is a paternal family history of DMII, dyslipidemia and Alzheimer’s. Social history: Travis parents are married. He has an older sister, age 24, and a younger sister, age 17. He currently lives in his parent’s home. He currently works full time at a hardware store. His hobbies are playing the bass guitar and car repair. He has a girlfriend, of 7 months, which is an intimate relationship. He has had three previous partners and reports 100% condom use. He denies intimate partner violence. He denies any history of emotional, physical, or sexual abuse. He denies the use of tobacco and illicit substances, including marijuana. He endorses drinking alcohol 1-2 times per month, approximately four beers, and denies drinking and driving. He does consistentlywear his seat belt. He has never had legal issues. Review of systems: non contributory Vitals: 76″ tall, 81 kg, 108/ 70, 68, 18, 98.7 Current mental status exam: This is a well-nourishedCaucasian male. He looks his stated age He is clean shaven, well groomed and casually dressed. His eye contact is fluctuant. He is somewhat distracted and psychomotor activity is within normal limits. His mood is euthymic and affect is congruent. He denies suicidal ideation, homicidal ideation and psychotic symptoms. There is no evidence to suggest otherwise. He is oriented to person, place, time and situation. His memory is grossly intact as evidenced by recalling recent and remote events. His short term recall is 3/3 immediately and 2/3 at 5 min. Abstract reasoning is appropriate. His use of vocabulary and fund of knowledge is in the average to above average range. His insight and judgment is good.

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