Subjective:

CC (chief complaint): Has been having headaches and stomachaches, and per the request of her pediatric provider should be seen for further evaluation.

HPI: M.J. 9 year old female, presents with her mother. M.J. has been experiencing physical symptoms of head aches and stomachaches. According to her mother these symptoms having been happening more and more since the holidays three months prior. Her mother is concerned because M.J. has been having these symptoms and in additon to these symptoms has not wanted to go to school. She cries prior to school and then tells the teacher she has a stomach ache while at school in order to have her mother come and pick her up. She has been missing multiple days at school in the past three months. Recently she had to be carried into the school by the principal after her mother tried to drop her off and she refused to get out of the car. This was a very embarrassing incident for both M.J. and her mother. She states she doesn't like school because of the work they give her. She denies that any of the teachers or other students are mean to her. She states that she is scared of leaving her house to go to school because she has a fear of being kidnapped. She denies that anyone has ever tried to kidnap her or hurt her in anyway. She denies that she has ever known anyone who has been kidnapped. Her mother denies any traumatic events happening to her daughter or even at the school or her home.

Past Psychiatric History:

M.J. has never been diagnosed or treated for any psychiatric mental illness in the past. She is under the care of her mother and father. Her mother is with her today to help present her case during this evalution. She has never had any hospilizations nor has she attempted any medication trials. She is not currently being seen by any therapist.

Substance Current Use and History:There is none.

Family Psychiatric/Substance Use History:There is no known family history.

Psychosocial History: M.J. lives with her mother and father, she is the youngest of three children. She has an older brother who is twelve and an older sister who is 14. She attends grade school but lately she does not want to attend. She has no legal history, no history of trauma. She does have a history of having a temper per her mother.

Medical History: No history of surgical or hospitalizations

• Current Medications: She is not currently prescribed any medications.
• Allergies: NKDA
• Reproductive Hx: not sexually active, has never nor been she currently pregnant.

ROS:

• GENERAL: Negative for chills, fever, malaise/fatigue, and weight loss, well nourished
• HEENT: negative for hearing loss, moist mucous membranes, no scleral icterus
• SKIN: Negative for rash or itching, no bruises and no ulceration
• CARDIOVASCULAR: negative for chest pain, regular rate and rhythm, no murmur
• RESPIRATORY: negative for shortness of breath, clear to auscultation bilaterally.
• GASTROINTESTINAL: negative for constipation or diarrhea, has a picky appetite
• GENITOURINARY: negative for any urinary tract infections, no dysuria
• NEUROLOGICAL: negative for dizziness or headaches
• MUSCULOSKELETAL: negative for pain
• HEMATOLOGIC: negative for splenectomy
• LYMPHATICS: negative for swollen nodes
• ENDOCRINOLOGIC: negative for any thyroid disease or diabetes.

Objective:

Physical exam as documented by the PCP

Vital Signs T-98, P-70, R-24, B/P 110/68, Ht 45 inches, Wt 57lbs, Vaccinations up to date and on target with developmental milestones.

Diagnostic results:: CBC, CMP, Urine Pregnancy test (Results not available).

Assessment:

Mental Status Examination: During the assessment with M.J. her mother Mrs. J was asked if she could step out of the room for a few minutes. M.J was reluctant to let her leave and physically grabbed her arm so she couldn't leave the room. As soon as her mom left M.J. tried to follow her out of the room. When asked how she felt regarding her mother leaving, M.J. responded with "I'm scared". When delving further into this M.J. is afraid that her mother will leave and never come back. She denies that she has ever been left before, or threatened by her mother or anyone else that they were going to leave and never come back. M.J. stated she has nightmares about being left, and that her mommy and daddy are in a car accident. She denies that either her parents or anyone else she knows has have ever been in a car accident. She states she is afraid of the dark. During this part of the assessment, she becomes very adamant that she must go and get her mother and when asked if she could just wait a minute longer, she states "NO!" she goes out of the room but comes back seconds later with a fear in her eyes. Stating she can't find her mother, seconds later her mother arrives, and she is overwhelmed, and they hug. Her mother denies that MJ has ever been left or that she has ever experienced any trauma at home or at school. She denies that she has ever been physically touched inappropriately by anyone.

Using credible sources and information from this case study

1. what are three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.

2. 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?

3. What would you do differently with this client if you could conduct the session over, what kind of questions would you ask?

4. In reflection to this case study discuss any legal/ethical considerations for this client of 8 years old (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).