case study

Case study:

J.N is a 16 y/o female brought to the clinic for evaluation by her mother. Per mother, the patient has been isolated, away from her family and friends, spent most time alone since she broke up with her boyfriend over a month ago. The patient has been skipping multiple meals or eating some days, continuously crying and upset at everyone and about everything. During the assessment, the patient was sobbing, and looking down, describe her mood as sad, hopeless, not a good person, low in energy and motivation; patient verbalized suicidal thoughts, denies plan to harm self or others, the patient was able to contract for safety. The patient stated, "everything just collapsed on me, and I wasn't expecting it. The patient will not be elaborated about the breakup. KADS-11 Depression scale was used for patient screening in which the patient score 19 out of 33.

Assignment

· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis?

· What is the duration and severity of their symptoms?

· How are their symptoms impacting their functioning in life?

· Objective: What observations did you make during the psychiatric assessment? 

· Assessment: Discuss their mental status examination results.

· What were your differential diagnoses?

· Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority.

· What was your primary diagnosis and why?

· Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.

· Plan: What was your plan for psychotherapy?

· What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. 

· Also be sure to include at least one health promotion activity and one patient education strategy.

· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.