Symptom Analysis Evaluation Instructions
Review the case study assignment for this module and complete the SAE Sections using the template. Remember to use at least five references and appropriate APA in-text citations and reference list not older than five years.
A. Health History/History of Present Illness: Identify history questions to be obtained to discriminate critical characteristics of the presenting chief complaint (symptom). Consider COLDSPA (Characteristics, Onset, Lingering, Duration, Stressors, Precipitating factors/triggers, Alleviating factors).
B. Differential Diagnosis: Delineate 4 differential diagnosis that could support the chief complaint and HPI. The differential diagnosis has to support the above symptoms in relation to pertinent answers given the history. MOST 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 seven component of MSE- Appearance, Behavior, Speech, Affect, Thought process, Thought content, Cognitive examination (level of awareness, Attention and Concentration, Memory, Orientation etc).
D. Pathophysiology: Delineate the neurophysiology, pathophysiology and etiology of each of the 4 differential diagnosis.
E. Diagnostic Testing: Delineate what diagnostic tests and screening tools would be appropriate for each of the 4 differential diagnosis.
F. Analysis: Delineate your final assessment along with rationale. Identify the primary diagnosis from the 4 differential diagnosis 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-medication class, non-pharmacotherapy) for the primary diagnosis.
