NURS6635: Week 10 – Assignment

CASE STUDY

Assessing and Diagnosing Patients with Neurocognitive and Neurodevelopmental Disorders
CC (chief complaint): “Yeah, you asked me to have some of her teachers fill out the
forms, and so, I had two, and I filled out one.” (Training Title 48, 2017)
HPI: Sarah is a nine-year-old African American child. She has a short attention span
which is affecting her school grades. It was recommended that she visit the therapist for
evaluation for the conduct. She was accompanied by her mother, Mrs. Higgins. Sarah’s mother
was given some questionnaires to complete and some to be completed by Sarah’s teacher about
her conduct at school and at home. Mrs. Higgins completed the questionnaires and returned them
to the therapist. Mrs. Higgins reports that at home and school, Sarah tends to be very is forgetful,
daydreams, hyperactive, inattentive, misplaces her objects, and fidgets. According to the mother,
she noticed this behavior about Sarah when Sarah was younger. She remembered her visit to the
zoo with Sarah and she would stick her hands into bars where animals could bite her. She would
also jump into the swimming pool even though she knows that she cannot swim. (Training Title
48, 2017).
Past Psychiatric History

• General Statement: The client is a nine-year-old female with poor school
  performance. 
• Caregivers: Mother.
• Hospitalizations: No hospitalization history.
• Medication trials: No previous medication trial.
• Psychotherapy or Previous Psychiatric Diagnosis: None diagnosed
  Substance Current Use and History: No previous or present substance use.

Family Psychiatric/Substance Use History: No Family Psychiatric/Substance Use
History:
Psychosocial History: Sarah is a fourth-grade elementary school student. She lives with
her mother because her parents are separated. She has a dog named Conley who she likes to play
with a lot. Her nutritional status is poor due to her inability to sit still during meals. She loves
playing video games, paintings, and visiting museums.
Medical History: No medical history.

• Current Medications: No current medications
• Allergies: No known allergies
• Reproductive Hx: N/A
  ROS: 
• GENERAL: Sarah does not look well-nourished, but she is not in no apparent distress.
• HEENT: Head: no headache Eyes: No vision problem. Ears: No ringing or hearing loss.
  Nose: No nasal drainage, Throat: No sore throat
• SKIN: Clean and dry.
• CARDIOVASCULAR No cardiovascular problems
• RESPIRATORY: No asthma or respiratory problems.
• GASTROINTESTINAL: Poor appetite.
• GENITOURINARY: No urinary issues or bed wetting.
• NEUROLOGICAL: No headache or dizziness.
• MUSCULOSKELETAL: No muscle or joint pain.
• HEMATOLOGIC: No Anemia
• LYMPHATICS: No history of enlarged lymph nodes.
• ENDOCRINOLOGIC: No complaint of sweating, cold or heat intolerance.
  Physical exam: Head is normocephalic; PERRLA, no apparent physical abnormalities
  observed. The skin is clean, dry and intact. She is able to moves all her extremities without any
  complexities (Training Title 48, 2017)
  Assessment
  Mental Status Examination: The client is a nine-year-old African American female child
  who appears her stated age but slightly slender due to poor nutritional intake. She is dressed
  appropriately and well kempt. She is alert and oriented to self, place, time, situation but forgetful.
  She is cordial and polite. Often, she needs regular redirection as she is easily distracted. Her
  speech is age-appropriate. No suicidal or homicidal thought processes noted in the course of the
  meeting (Training Title 48, 2017).

Based on the above case study, I have provided you with one differential diagnoses
(but 3 needed). I want you to write on them just as you did my previous assignment.
Differential Diagnoses:

1. ADHD Explain each and state why
2. ?????
3. ??????

Please elaborate each according to DSM-5 criteria and why the other two dx were ruled out. In
other words, compare the DSM-5 diagnostic criteria for each differential diagnosis and explain
what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the

critical-thinking process that led you to the primary diagnosis you selected. Include pertinent
positives and pertinent negatives for the specific patient case.
Diagnostic results and Lab tests:

What diagnostic test and Lab work will you order for this patient (This information is not
provided but you must provide)