Patient key information Assignment Sample

Patient key information
The case study assessment involves a patient aged 26 year old, currently living with
his mother and two older brothers. The patient exhibited unique behavioural habits
which lead to developing loss of interests in doing tasks. He started experiencing
dissociative behaviour, medical care was offered at psychiatric ward, however he
was not able to have ward level activities. The family states that he losses interest
very shortly and unable to concentrate. His medical history has been unable to
establish psychosis symptoms. The patient has been having intermittent ward
admissions throughout.
Differential diagnosis
Differential diagnosis is key in the patient in that, there is a possibility of having more
than one diagnosis. Differentiating between different diagnoses to determine actual
diagnosis is key in the patient, ruling out malingering and factious disorder. The
patient is not faking any symptoms as there were no psychotic symptoms displayed.
Malingering often refers to state of a patient feeling to benefit on a particular
diagnosis while the factitious disorder is when one derives psychological benefits
after the taking the role of sick persons. (Ferri, 2010)
Ruling out drug related causes for the patient is key. Some drugs often cause
psychotic depression, which often reflects drug abuse. From the medical assessment
the patient is not on any medication or drug related activities. Ruling out of general
medications is key. From the medical history by her mother, the patient is not on
any influence of drugs.
Further assessment of mood disorders is key for the patient. It is common with
persons having Down syndrome. The differential diagnosis associated with this is
ruling out the presence of thyroid disorders, sleep related disorders and vitamin b12
for the patient. The patient does not exhibit any of the established risks factors.
Eliminating of mood disorder for the patient is key. As from the key indicators there
are signs of low and high mood stages for the patient, further positive mood
disorder exhibit physical symptoms of depression and unexplained headaches.
Further due to absence of episodes occurrences the patient is negative of bipolar
disorders and cylothamic disorders. (Baud et al, 2011)
Final diagnosis
The final diagnosis for this patient is attention deficit hyperactivity disorder. It is
characterised by neuron developmental disorder which is occasioned by lack of
paying attention and difficulty in controlling behaviour for the patient, (APA,
2013). It is marked by an ongoing pattern of inattention and hyperactivity which is
impulsive. Symptoms characterised by the patient exhibit low mood disorder and
mood swings. The patient is exhibiting antisocial behaviour.
Treatment plan
- Medication
Medication management for the patient involves counselling and use of medication
laxatives. Treatment for the patient offers long term treatment and improves long
term outcomes. Appropriate medications include use of alpha -2-adrenargic
receptor
- Therapies
Use of behavioural therapies in ADHD is essential in first line treatment, therapies
include;
- Psycho educational therapy
- Behaviour therapy
- Inter personal psychotherapy

- Referrals
- Key referrals for the patient include a recommendation for peer counsellor to often
visits the patient and offer emotional support which enables sharing and
overcoming of once fears.
- Key referral is a review by a social health worker in assessing environmental
factors which might influence the patient towards exhibiting ADHD condition.
- Health education
Health education is geared towards effective medicinal review and proper date
management for the patient. A Meta analysis study has found out that
supplementation with free fatty acids foods can have improved effects on ADHD
medication. (Tomaska & Brooke-Tylor, 2014)
Further improved intake of zinc has shown to increase recovery rate for ADHD,
hence key health education for consumption of such foods.
References
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.). Arlington: American Psychiatric Publishing. pp. 59–65. ISBN 978-0-
89042-555-8
Baud P, Perroud N, Aubry JM (June 2011). "[Bipolar disorder and attention
deficit/hyperactivity disorder in adults: differential diagnosis or comorbidity]". Rev Med
Suisse (in French). 7 (297): 1219–1222. PMID 21717696
Ferri, F. F. (2010). Ferri's differential diagnosis: a practical guide to the differential diagnosis
of symptoms, signs, and clinical disorders. Elsevier Health Sciences.
Tomaska LD, Brooke-Taylor S (2014). "Food Additives – General". In Motarjemi Y, Moy
GG, Todd EC. Encyclopedia of Food Safety. 3 (1st ed.). Amsterdam: Elsevier/Academic
Press. pp. 449–54. ISBN 978-0-12-378613-5