Discuss Subjective Data Question & Answer Guide (With Explanation)

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Original Question

Discuss Subjective data: • Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS Discuss Objective data: • 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 Discuss results of Assessment: • Results of the mental status examination • Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms. • A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected. Reflect on this case. Discuss what you learned and what you might do differently. ============================================================================================== Subjective: CC (chief complaint): “I have suicidal feeling.” HPI: AC is a 16-year-old female who presents for evaluation of suicidal ideations. Mom indicates she has had depression for over a year has been receiving Wellbutrin as an outpatient without improvement. Pt does feel the focus is not where it should be yet. Mon reports significant trauma that has become known or occurred within the past year. Report’s school is stressful. Notes tough time with focused both directly and distractions. States she is forgetful with assignments at times also her parents she feels expect her to be perfect like her sister who is not something this is Pt struggles of poor focused and so the goals they set such as no 0 work assignment are not possible. States she often fights with father as he expects perfection. She states she has come to the point of not caring. States most of the time has no appetite but at other thinks she does not eat to replace past SIB of cutting. She reports her anxiety is different in that she often thinks about what-if scenarios more constantly. She does say being irritable with muscle tension when anxious. States she is usually more fatigues as well. Panic attacks come at varying times per week. Pt does not like being alone with depression. She reports preferring to isolate. She does feel that Zoloft has lessened the thoughts not to exist and increased motivation. Mom says that the patient’s friend committed suicide over the last year and has lasted several other family members. Ove the last week, the patient has been cutting her arms with objects. Substance Current Use: The patient denies using alcohol and illegal drugs. Medical History: Current Medications: Zoloft 25 mg daily and Focalin XR 10 mg every morning Allergies: Latex and Peanut Reproductive Hx: No children. Pregnant test urine negative. Past Psychiatric History: Hospitlization: None Psychiatrist/Therapist:None Previous SA: Reports puttingher head under water in the bath in a drowining attempt 2 years ago. Self injurious behavior: cutting forearms, intermittently occurring since 5th grade, most recently last week. ROS: GENERAL: Alert and oriented and responds appropriately to questions Well appearing; well-nourished; in no distress, non-toxic Head: normocephalic; atraumatic ENT: eye: Extraocular movements intact; conjunctivae clear, sclera non-icteric; has 504/IEP for hearing loss SKIN: abrasions to the left forearm. CARDIOVASCULAR: Negative for cough RESPIRATORY: Negative for cough GASTROINTESTINAL: Negative for vomiting GENITOURINARY: Denies painful urination NEUROLOGICAL: Denies dizziness, unsteady feet, seizure, tics MUSCULOSKELETAL: The patient denies joint pain. HEMATOLOGIC: No abnormal bleeding and bruising noted LYMPHATICS: denies any swollen nodes ENDOCRINOLOGIC: denies polyuria, polydipsia, and polyphagia Objective: Diagnostic results: Lab urine drug screen results normal, Negative pregnant test. TSH, CMP, Liver panel. To evaluate the real-world impact of using a commercially available combinatorial pharmacogenomic (CPGx) test on medication management and clinical outcomes in children and adolescents treated at a tertiary care psychiatry practice (Dagar et al., 2022). Assessment: Mental Status Examination: The patient is a 16-year-old Caucasian female. Appearance is female, groomed, and dressed in hospital clothing. Behavior is normal posture. Patient with good eye contact and guarded. Speech is normal in rate, rhythm, volume. Thought processes are linear, logical, and goal-directed. Thought content is normal. The mood is “depressed.” Affect is irritable, appropriate range. Perception reveals she denies hallucinations. The patient endorses suicidal ideations, denies suicidal plans, denies homicidal ideations, and denies homicidal intent. The level of consciousness is awake and alert. Cognition is oriented, and insight is partial. Judgment is partial. In psychiatric interviews, a clinical question made to produce a specific symptom description is sometimes met with patients’ self-disclosure of their subjective experience. The patient’s topical emphasis on their expertise does something other than just answering the question (Savander et al., 2021). Differential Diagnosis Major Depressive Disorder: According to DSM -5, depressed mood; loss of interest inactivates or pleases longer, two weeks to 4 weeks (Hilt & Nussbaum, 2016). Pt endorses depressed or sad mood and endorses diminished interest or pleasure in activities and endorses fatigue or loss of energy, and endorses feeling of guilt or worthlessness, and endorses impaired concentration, and endorses suicidal ideations, and endorses that symptom cause clinical distress or impairment (Kanter et al., 2018). The patient has been feeling depressed for the past 3-4 months d suicidal ideation with a plan to cut her arm. Generalized Anxiety Disorder: Endorses excessive anxiety and worry more days than not and endorses restlessness or feeling on edge (Strohle et al., 2018). Endorses being easily fatigued and endorses irritability, endorses muscle tension, endorses anxiety, and worry cause distress. DSM-5 stated GAD is that restless, easy fatigability, difficulty concentrating, irritability, and avoidance of situation last 3 to 6 months or longer (Hilt & Nussbaum, 2016). Post-Traumatic Stress: Endorses directly experiencing a traumatic event endorses recurrent involuntary and intrusive distressing memories of the trauma. PTSD hallmark symptoms are intrusive experiences, uncomfortable memories, dreams, flashbacks, reminder exposure distress physiology reactions (Hilt & Nussbaum, 2016). Endorses exaggerated negative beliefs about oneself or others or the world and endorses a persistent negative emotional state. Pt reports irritable behavior and angry outbursts and endorses problems with concentration. Endorses the disturbances causing significant distress or impairment. Trauma and PTSD in parents may impact parental distress and child abuse potential, potentially increasing children’s risk for the experience of child abuse and PTSD. Child and family interventions should consider child and parental trauma and PTSD as crucial factors. The PTSD symptom can be last longer than one month (Cross et al., 2018). Attention Deficit and Hyperactivity: Attention-Deficit / Hyperactivity Disorder (ADHD) is children’s most common behavioral disorder. The main symptoms of ADHD in children are characterized by difficulty paying attention and impulsive and hyperactive behavior that interferes with function or development (Ristiyanti et al., 2021). There is evidence of failing to give close attention or making careless mistakes and evidence of difficulty sustaining attention. DSM-5 reports inattention, make careless mistakes, cannot maintain awareness, does not seem to listen, often does not follow through, struggles to organize tasks, and symptom is six months or longer (Hilt & Nussbaum, 2016). Plan Risk and benefit of treatment discussed with patient and guardian. Referrals have been made to outpatient counseling. Will increase Focalin XR to 15 mg QAM and Zoloft 50 mg daily. We discussed increasing both medications to optimize further symptom control, which they agreed with. She does voice SI but has no plan. She further oriented and discussed her plan, stating that it gave her the drive to continue. She downplays the significance of her symptoms at times and admits her behaviors are coping mechanisms. She is a moderate risk but not felt to be an imminent threat to herself or others. They were told to call the office or utilize ED for any new or worsening symptoms. Reflections The diagnosis matches the symptoms. I would ask risks and benefits of treatment discuss them with the patient and mother. I recommend patient attend family therapy, if possible, to participate during those groups. Since patient has conflict with her father, it would better for the family therapy. I would encourage patient to be medication compliant by explaining to patient that we increased home medication and observed how patient would react. I would educate patient on th effectiveness of medication compliant combined with therapy session. Patient would be encouraged to participate in his care an during treatment plan. References Cross, D., Vance, L. A., Kim, Y. J., Ruchard, A. L., Fox, N., Jovanovic, T., & Bradley, B. (2018). Trauma exposure, PTSD, and parenting in a community sample of low-income, predominantly African American mothers and children. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 327-335. https://doi.org/10.1037/tra0000264 Dagar, A., Cherlopalle, S., Ahuja, V., Senko, L., Butler, R. S., Austerman, J., Anand, A., & Falcone, T. (2022). Real-world experience of using combinatorial pharmacogenomic test in children and adolescents with depression and anxiety. Journal of Psychiatric Research, 146, 83-86. https://doi.org/10.1016/j.jpsychires.2021.12.037 Enikö Èva Savander, Jukka Hintikka, Mariel Wuolio, & Anssi Peräkylä. (2021). The Patients’ Practises Disclosing Subjective Experiences in the Psychiatric Intake Interview. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.605760 Hilt, R. J., & Nussbaum, A. M. (2016). DSM-5 pocket guide for child and adolescent mental health (First edition.). American Psychiatric Association Publishing. Kanter, J. W., Busch, A. M., Weeks, C. E., & Landes, S. J. (2018). The nature of clinical depression: symptoms, syndromes, and behavior analysis. The Behavior analyst, 31(1), 1-21. https://doi.org/10.1007/BF03392158 Ristiyanti, N., Dirgantoro, B., & Setianingsih, C. (2021). Behavioral Disorder Test to Identify Attention-Deficit / Hyperactivity Disorder (ADHD) in Children Using Fuzzy Algorithm. 2021 IEEE International Conference on Internet of Things and Intelligence Systems (IoTaIS), Internet of Things and Intelligence Systems (IoTaIS), 2021 IEEE International Conference On, 234-240. https://doi.org/10.1109/IoTaIS53735.2021.9628642 Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Arzteblatt international, 155(37), 611-620. https://doi.org/10.3238/arztebl.2018.0611 Please revise the underlined parts and proofread for me. thank you.

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