SYMPTOM ANALYSIS EVALUATION ASSIGNMENT INSTRUCTIONS
OVERVIEW
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 history questions to be obtained to discriminate critical characteristics of the presenting chief complaint (symptom). 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. Must use appropriate DSM 5 diagnosis and provide rationale for each choice differential diagnosis base 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 component of MSE listed- Appearance, Behavior, Speech, Affect, Thought process, Thought content, Insight, Judgement, Cognitive examination (level of awareness, Attention and Concentration, Memory, Orientation etc.). Must support with literature and use the appropriate descriptors in each component. Avoid using “normal” or “Good” as a descriptor.
D. Pathophysiology: Delineate the neurophysiology, pathophysiology and etiology of each of the 4 differential diagnoses.
E. Diagnostic Testing: Delineate what diagnostic tests would you obtain to rule out medical issues that mimic each of the differential diagnosis and mental health screening tools.
F. Analysis: Delineate your final assessment along with rationale. Identify the primary diagnosis from the 4 differential diagnoses and support with the DSM 5. Discuss why the other differential diagnosis are less likely for the case.
G. Treatment Plan: Delineate appropriate treatment plan (pharmacotherapy and non-pharmacotherapy) for the primary diagnosis.
