Review the case study assignment for this module and complete the Symptom Analysis Evaluation (SAE) Sections using the template. The first SAE assignment is an individual assignment. The second SAE is a group assignment. Remember to use at least five references and appropriate APA in-text citations and reference lists.
INSTRUCTIONS
A. Health History/History of Present Illness: Identify appropriate history questions to be asked of your patient to discriminate critical characteristics or attributes about the above-presenting complaint. Ensure to ask questions that are open-ended and facilitate meaningful dialogue pertinent to the issues. Incorporate COLDSPA (Characteristics, Onset, Lingering, Duration, Stressors, Precipitating factors/triggers, Alleviating factors).
B. Differential Diagnosis: Delineate 4 differential diagnoses that could support the chief complaint and HPI. The differential diagnosis must support the above symptoms in relation to pertinent answers given in the history. Use appropriate DSM 5 diagnosis and provide the rationale for each choice differential diagnosis based on the presenting case.
C. Mental Status Examination: Delineate mental status exam findings would be associated with each listed differential diagnosis. Document the subjective data that the patient might have reported. Use all components of MSE listed- appearance, behavior, speech, affect, mood, thought process, thought content, insight, judgment, cognitive examination (level of awareness, attention and concentration, memory, Orientation, etc.), and Intelligence. Must support with literature and use the appropriate descriiptors in each component. Avoid using “normal,” “within normal limits” or “Good” as a descriiptor.
D. Pathophysiology: Delineate the neurophysiology, pathophysiology, and/or etiology of each of the 4 differential diagnoses.
E. Diagnostic Testing: Delineate the diagnostic tests needed to rule out medical issues that mimic each of the differential diagnoses. Discuss the psychiatric screening tools for each of the differential diagnoses. Provide the rationale for selecting the screening tools and diagnostic tests.
F. Analysis: Delineate your final assessment along with the rationale. Identify the primary diagnosis from the 4 differential diagnoses and support it with the DSM 5. Discuss why the other differential diagnoses are less likely for the case.
G. Treatment Plan: Delineate an appropriate treatment plan (pharmacotherapy and non-pharmacotherapy) for the primary diagnosis. Address safety issues and black box warnings.
