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Please need two different responses from the attached presentation.Each response should be 2paragraphs including atleast a reference.

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Initials: T.A.
Age: 15
Gender: Male
Race: African-American
Subjective Data
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CC (chief complaint): T.A. stated, “I just cannot help myself sometimes. I feel like my teachers
don’t get me at all. In fact, nobody gets me. I don’t even think I belong anywhere. Sometimes I
just get up and walk out of the classroom when I feel sad because some student’s pick on me.”
HPI: T.A., a 15-year-old African American male, presented for mental health evaluation
accompanied by his mother who provided consent for treatment. He is in 9th grade and his chief
complaint encompassed academic challenges, disruptive behavior, and occasional sadness. T.A.
expressed feelings of being overwhelmed with academic responsibilities and social interactions
in high school. He felt isolated, stating that his teachers and peers did not comprehend him. The
patient admitted to occasionally walking out of class as a coping mechanism. His mother
revealed that he exhibited disruptive behavior including inattentiveness and deception
concerning his academic achievement. She noted that the patient misses’ class because of
emotional anguish or being abused by peers, and she often gets notices of accounts of her
son’s disruptive behavior. These symptoms have been ongoing, affecting his daily functioning
and contributing to constant conflicts at school. The patient denied suicidal and homicidal
ideations.
Family History: The patient’s father has no psychiatric diagnosis, while the mother is diagnosed
with depression and anxiety and is currently taking medication for management. Two older
sisters have no mental health diagnosis. The younger brother has been diagnosed with adjustment
disorder and is receiving therapy every week.
Substance Current Use: No history of smoking, alcohol, or illicit drug use.
Medical History: No history of hospitalization, chronic illnesses, or major surgery.
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Current Medications: The patient is currently on Bupropion XL 100 mg once daily, Concerta
ER 27 mg once daily, and Vistaril 25 mg twice daily as needed.
Allergies: The patient denied allergies to drugs, food substances, and environmental factors.
Reproductive Hx: Not applicable (adolescent patient).
Review of Systems (ROS)
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General: Denied recent fluctuations in energy levels, voiding patterns, eating habits, and
night sweats.
•
HEENT: Denied history of trauma, scalp anomalies, visual changes, nasal congestion,
ear discharges, and throat infections.
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Skin: No reported changes in skin texture and general appearance. No history of pallor,
cyanosis, erythema, or abnormalities such as rashes and lesions were reported.
•
Cardiovascular: Denied symptoms such as chest pain, pressure, discomfort, fatigue,
palpitations, and edema.
•
Respiratory: No previous respiratory infections or surgeries, exercise intolerance, cough
production, wheezing, exposure to smoke, or labored breathing.
•
Gastrointestinal: No history of gastrointestinal disorders, abdominal pain, bloating,
unintended weight loss, bloody stools, nausea, vomiting, or diarrhea.
•
Neurological: Denied history of head injuries, headaches, dizziness, seizures, changes in
sensation, weakness, coordination difficulties, or changes in cognition.
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•
Musculoskeletal: No joint pain, stiffness, swelling, weakness, muscle rigidity, history of
musculoskeletal conditions, or limitations in movement.
•
Hematological: Denied history of anemia, bleeding disorders, blood transfusions,
hematological malignancies, pallor, bruising, bleeding, or recurrent infections.
•
Endocrinological: Denied recent changes in weight, energy levels, mood, sleep patterns,
thirst, thyroid disorders, polydipsia, and polyuria.
Objective Data
Physical Exam:
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Vital Signs: BP 122/68, Pulse 80, RR 17, O2 sat 98% Temp 98.6 ºF, weight 136 pounds
height 5’6, BMI 26.7.
•
HEENT: The head is normal with no apparent asymmetry, tenderness, masses, or signs
of trauma. In the eyes, the PERRLA, pupillary reflexes are equal and reactive, and signs
of inflammation on the conjunctiva. No signs of anomalies, discharge, or ear
inflammation. The nose is patent with septal integrity and no observable signs of
congestion. Lastly, the throat has no signs of infection.
Diagnostic results:
In this case, various tests and results are imperative in diagnosing the patient. Thyroid
Function Tests (TFTs) are crucial in ruling out thyroid disorders, such as hypothyroidism or
hyperthyroidism, which manifest with mood disturbances, fatigue, and cognitive impairment. A
complete Blood Count (CBC) can help rule out anemia and other blood disorders that may
contribute to fatigue and affect mood. Additionally, diagnostic instruments such as the Patient
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Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) are integral
in assessing the patient’s symptoms. PHQ-9 is a new proposed diagnostic category for children
who have persistent and recurrent mood dysregulation (Walter et al., 2022). The patient’s score
of 12 out of 27 indicates a moderate level of depressive symptoms, which aligns with T.A.’s
reported feelings of sadness, alienation, and disruptions in academic performance. Lastly, the
GAD-7 score of 14 out of 21 signifies a high level of anxiety symptoms. These scores further
support the diagnostic considerations for GAD and MDD.
Assessment:
Mental Status Examination:
T.A., a 15-year-old African American boy presented to the facility for mental health
assessment. He was alert and oriented to time, person, place, and event during the mental status
assessment. He is cooperative and actively engages in the evaluation, demonstrating proper eye
contact and a willingness to participate. His physical appearance is neat and well-groomed, with
appropriate attire and no signs of abnormal motor activity. He exhibits no evident motor
abnormalities, observable signs of restlessness, agitation, or psychomotor retardation. He speaks
intelligibly, clearly, and with a typical volume and tone. The patient appears to have a goaloriented, rational mental process without any loose associations or idea flight. T.A. expressed
feelings of sadness and isolation and his affect appears constricted. He denied auditory or visual
hallucinations, delusional thinking, suicidal, and homicidal ideations. He maintains insight into
his condition, acknowledging difficulties in school, feelings of not belonging, and struggles with
disruptive behavior.
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Diagnostic Impression:
Disruptive Mood Dysregulation Disorder
The patient satisfies the requirements for Disruptive Mood Dysregulation Disorder
(DMDD) based on the CC, HPI, and diagnostic findings based on the components listed in the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Firstly, the
recurrent temper outbursts he experiences, manifested verbally and behaviorally, are inconsistent
with his developmental level. These outbursts are disproportionate to the provocation or stressor,
as evidenced by his reported reactions to feeling overwhelmed and being picked on by peers at
school (APA, 2022). Furthermore, T.A. reported a chronic irritable mood that is observable
through his expressions of sadness and a feeling of not belonging. This mood dysregulation
occurs frequently, on average three or more times per week, a common manifestation of this
condition (APA, 2022). The patient’s disruptive behaviors significantly impair his functioning in
social settings, particularly in school as reported by their mother aligning with DMDD.
Attention-Deficit Hyperactivity Disorder
The patient’s current symptoms also meet the requirements for Attention-Deficit
Hyperactivity Disorder (ADHD). T.A. exhibits inattentive conduct at school, as evidenced by his
overwhelming sentiments, difficulties finishing assignments and homework, and reports of
disruptive behavior. This inattention is supported by his tendency to lie about his grades,
indicating difficulty maintaining focus and organization, aligning with ADHD (APA, 2022).
Moreover, he has hyperactive-impulsive symptoms which are manifested through his impulsive
behavior, such as leaving the classroom when feeling sad and being considered disruptive in
school. These symptoms have been present since before the age of 12 which fits the ADHD
diagnosis (APA, 2022). The presence of these symptoms greatly impedes both his academic and
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social functioning, leading to difficulties in academic pursuits and disruptive behaviors that
negatively affect his relationships with peers and teachers.
Generalized Anxiety Disorder (GAD)
GAD is a differential diagnosis for T.A. He exhibits excessive worries and anxiety about
various events and activities, especially concerning his high school experiences, homework, and
class responsibilities. Although his worry is not proportionate to the actual risk, he finds it
challenging to control his anxious thoughts which is characteristic of GAD (APA, 2022). The
patient also admitted to experiencing restlessness as exhibited by his disruptive behaviors at
school, such as leaving the classroom when feeling upset due to peer interactions. In addition, he
reported experiencing feelings of unease and fatigue, which are consistent with the physiological
symptoms of GAD (APA, 2022). Lastly, the patient’s symptoms have persisted for a significant
duration, affecting his daily life and interpersonal relationships.
Major Depressive Disorder (MDD)
T.A. also exhibits symptoms that correlate with MDD as outlined in the DSM-5. Firstly,
he experiences widespread feelings of sadness, hopelessness, and a feeling of being disconnected
from the world, which aligns with the criterion of depressive mood persisting most of the time
(APA, 2022). Secondly, his day-to-day functioning has significantly changed, as seen through
difficulties at school, disruptive behavior, and challenges keeping up with academic
responsibilities. These changes in behavior align with the DSM-5 criteria requiring marked
impairment in social or occupational functioning. Additionally, T.A. has shown a decrease in
enjoyment and interest in activities he previously found enjoyable, as indicated by his lack of
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involvement in school and extracurricular activities. This disengagement has been ongoing for a
considerable time and has significantly affected patient’s daily life, common symptom in MDD.
Reflections:
Reflecting on this case, if I had the opportunity to conduct the session again, I would
prioritize exploring the intricacies of his social interactions, including bullying experiences and
interpersonal relationships, to acquire a more comprehensive comprehension of his surroundings.
Bullying can lead to feelings of depression, anxiety, loneliness, and even suicidal thoughts (Gunn
& Goldstein, 2020). On the other hand, interpersonal relationships can affect the development of
self-esteem, which is a crucial factor in maintaining good mental health. Furthermore, I would
encourage the school to play a more active role in the assessment process by seeking the input of
teachers and school counselors. Given the complex interplay of DMDD, ADHD, GAD, and
MDD, a collaborative approach involving educators would enhance the formulation of a holistic
intervention plan.
The success of interventions for T.A. depends on the involvement of T.A. and his family
in therapy, adherence to the treatment plan, and the effectiveness of school-based interventions.
A multidisciplinary approach, including psychotherapy, medication management, and schoolbased strategies, may be more impactful. It can lead to better outcomes, such as improved
academic performance, reduced disruptive behaviors, and enhanced coping skills. However, it’s
crucial to acknowledge that progress may be gradual, and periodic reviews and adjustments to
the treatment plan may be necessary.
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The importance of maintaining informed consent and confidentiality in legal and ethical
considerations cannot be understated. It is crucial to ensure that patient’s privacy boundaries are
respected while also sharing information with his school for his benefit. Striking this balance
requires clear communication with both the patient and his mother about the necessity and
limitations of information exchange (Pallocci et al., 2023). Furthermore, his struggles in school
and behavioral disruptions may be a result of interactions with peers and bullying, which
highlights the value of social determinants of health in school counseling and anti-bullying
programs. To be effective, any interventions must take into account his age and cultural
background, recognizing the specific challenges faced by African American adolescents.
Incorporating activities that align with his interests, such as basketball and football, may also
contribute positively. Emphasizing stress management techniques, alongside regular physical
activity, can enhance overall well-being.
Case Formulation and Treatment Plan:
T.A., a 15-year-old African American boy, came with a complex clinical picture marked
by academic challenges, disruptive behavior, and occasional sadness. Multiple factors contribute
to his presentation. The transition to high school, academic pressures, and peer interactions
serves as immediate stressors, triggering his disruptive behaviors, mood challenges, and
academic difficulties. A family history of mental health challenges, particularly the mother’s
depression and anxiety, may contribute to T.A.’s vulnerability, acting as the predisposing factor.
Additionally, his age and developmental stage impact how he navigates social and academic
stressors. The perpetuating factors for this patient include ongoing disruptive behaviors at school,
academic struggles, and peer conflicts. Limited coping mechanisms exacerbate his difficulties in
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managing stressors. Supportive family dynamics, participation in sports activities (basketball and
football), and the presence of a treatment-seeking and supportive mother act as protective
factors.
The treatment plan for T.A. involves a multi-faceted approach to address his presenting
symptoms. Cognitive-behavioral therapy (CBT) could be integrated to target mood dysregulation
and disruptive behaviors (Sheybani et al., 2022). Recognizing the value of family support as a
protective factor, the addition of family therapy strives to enhance communication within the
family system. A health promotion activity would be crucial in motivating the patient to
participate regularly in physical activities such as basketball and football, thereby encouraging
overall wellness. Besides, patient education emphasizes educating him on stress management
strategies aimed at providing them with effective coping mechanisms that can help manage
academic and social stressors.
Regarding medication, Bupropion XL and Concerta ER helps with both ADHD and
depression symptoms. For the immediate treatment of anxiety symptoms, Vistaril was provided
(Parker et al., 2021). Nonpharmacologic treatments could include mindfulness practices and
relaxation techniques to address anxiety. Art and music therapy should be considered as
alternative treatments for emotional expression and regulation. The initial assessment will be
made every two weeks, followed by ongoing reviews every 4-6 weeks to monitor medication
response and adjust the treatment plan if necessary. The frequency of reviews will vary
depending on the patient’s condition and response to treatment.
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Discussion Prompts
1. How might exploring the complexes of the patient’s social interactions contribute to a
holistic understanding of his mental health problems?
2. Considering the value of informed consent and confidentiality, how can a provider strike
a balance between respecting patient privacy and sharing pertinent information with the
school for the benefit of the patient?
3. In what ways can knowledge about bullying experiences and interpersonal relationships
affect the development of an effective intervention plan for the patient?
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PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at
their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
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References
American Psychiatry Association. (2022). Diagnostic and statistical manual for mental
disorders, 5th Ed.
Gunn, J. F., & Goldstein, S. E. (2020). Exploring the association between bullying victimization
and suicidal thoughts through theoretical frameworks of suicide. International Journal of
Bullying Prevention. https://doi.org/10.1007/s42380-020-00078-z
Pallocci, M., Treglia, M., Passalacqua, P., Tittarelli, R., Zanovello, C., De Luca, L., Caparrelli,
V., De Luna, V., Cisterna, A. M., Quintavalle, G., & Marsella, L. T. (2023). Informed
consent: Legal obligation or cornerstone of the care relationship? International Journal of
Environmental Research and Public Health, 20(3), 2118.
https://doi.org/10.3390/ijerph20032118
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Parker, E. L., Banfield, M., Fassnacht, D. B., Hatfield, T., & Kyrios, M. (2021). Contemporary
treatment of anxiety in primary care: A systematic review and meta-analysis of outcomes
in countries with universal healthcare. BMC Family Practice, 22(1).
https://doi.org/10.1186/s12875-021-01445-5
Sheybani, H., Mikaeili, N., & Narimani, M. (2022). The efficacy of cognitive behavior therapy
on emotion regulation and irritability of the students suffered from disruptive mood
dysregulation disorder. Journal of School Psychology, 11(1), 56–67.
https://doi.org/10.22098/jsp.2022.1569
Walter, H. J., Abright, A. R., Bukstein, O. G., Diamond, J., Keable, H., Ripperger-Suhler, J., &
Rockhill, C. (2022). Clinical practice guideline for the assessment and treatment of
children and adolescents with major and persistent depressive disorders. Journal of the
American Academy of Child & Adolescent Psychiatry, 62(5).
https://doi.org/10.1016/j.jaac.2022.10.001

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