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

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: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session? 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.

Patient selected:

History: Demi is a 5-year-old girl. This evaluation was requested by mother (Fantasia Jenkins) because Demi was diagnosed with Austism Spectrum D/O and she started showing aggression, melt down, and inattentive. She attends Autstic special needs school @ PS15.
Diagnosed with Autism on 5/5/2022.

Information Received From:

Demi\’s Parents

Autistic Process:
Demi exhibits signs of autistic process, characterized by impaired social interaction, verbal and nonverbal communication, and restricted and repetitive behavior. She was kicked out in pre-K because of the behavioral problem. She gets into physical altercations, throw things and hit people.
Impaired Social Interaction:
Demi exhibits a marked and sustained impairment of social interaction. She has difficulty making or sustaining friendships. There is no engagement in \”make believe\” or imitative play. There is no engagement in social play or games. Her understanding of social boundaries is poor.
Impaired Communication:
Demi exhibits a marked and sustained impairment of communication that affects both verbal and nonverbal skills. Language is delayed or has not developed appropriately. Demi\’s comprehension is impaired with difficulty interpreting literal and/or implied meanings. She is good with cite words and picture identifications.
Impaired Behavior:
Demi exhibits a marked and sustained impairment of behavior. Demi exhibits bizarre physical mannerisms. Demi becomes distressed over changes in the environment. Hypersensitivity to sound is exhibited, especially loud noises. She displays socially or emotionally inappropriate behavior.

Targeted Behaviors:
During the session, specific behaviors requiring therapeutic intervention were identified. She is having temper tantrums. Aggressive behavior has been displayed toward others.

Therapeutic Interventions:
Interventions were utilized during the session aimed at improving Demi\’s behavioral problems. Therapist used positive reinforcement to produce the desired behavioral response. Motivation was used in the following form(s): counting, singing, and playing music.

Sleep patterns is off: she has been waking up frequently.
She is a picky eater; Heights is 4 ft and weight 48 Ibs.
She saw neurologist, blood work done; Vitamin D level is low; She sometimes shows low mood, but mood has been stable and not that emotional since the vitamin D has been added into her supplement.

Past Psychiatric History:

Entirely negative. Demi has never been treated, counseled or hospitalized for a psychiatric condition. There is no history of emotional dyscontrol, unusual anxiety, or behavioral disturbance.

Social/Developmental History:

Childhood History:
Demi was born in NJ She was raised by her mother and father in a separate household. She is the only child.
Pregnancy History: Normal delivery.
Development History:
Single Words: non verbal only says single ways.

Family History:

Uncle carries diagnosis of autism.

Medical History:

Medical history is negative and Demi has no history of serious illness, injury, or hospitalization. Does not have a history of asthma, seizure disorder, head injury, concussion or heart problems. No medications are currently taken.
She had tissue removed form her left foot on 8/30/22; it was a day surgery.

Exam: distracted, casually groomed, and tense. Her speech cannot be tested. Mood cannot be assessed. Cognitive functioning was not formally tested today but appears clinically to be unchanged from previous examinations. She is easily distracted.

Diagnoses: The following Diagnoses are based on currently available information and may change as additional information becomes available.

Autistic disorder, F84.0 (ICD-10) (Active)

Therapy Content/Clinical Summary:
The patient\’s mom expressed many aggression and melt down feelings this session.

The focus of today\’s session was on helping to increase insight and understanding. The focus of today\’s session was on stabilizing the patient. The patient\’s mom was today given emotional support. Demi\’s mom was given medication instructions and education. Demi\’s mom was counseled and educated regarding the risks and benefits of treatment. Demi\’s mom was counseled and educated regarding the importance and scheduling of all follow up instructions.

Instructions / Recommendations / Plan:

Information provided for mom on Risperidone and Abilify;
Instructed to fax or email the copy of her most recent blood work for review before initiating medications.