Case Presentation

Client is a 16-year-old African American brought to the clinic for evaluation by his mother as requested by the school counselor. Mother reported that the client “Likes to do what he wants to do and hates to be challenged and refuse to follow simple rules/directions at home and in school, as well as a lack of respect for anyone. The behavior started approximately 2 years ago and its more frequent lately. Client denies any past or present history of suicidal/homicidal ideation or thoughts of harming self/others. Client denies any previous engagement in mental health services. Client reports that he previously intended to stab someone in 2018 but stated that his friends stopped him. Client denies any current homicidal ideation. Client reports significant difficulty at school that are directly related to his behavior. Reports a history of suspensions due to aggressive behavior at school. Client reports that he has difficulty paying attention and therefore does not regularly attend classes.

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

 

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results: what diagnostic test is needed for the diagnosis

Assessment:

Mental Status Examination:

Diagnostic Impression:

 

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.

Reflection notes: What would you do differently with this patient if you could conduct the session over? 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.

Case Formulation

Treatment Plan: Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? 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.