CC (chief complaint): “My mum thought you would help me be better.”
HPI: The video depicts Dev Cordoba, a 7-year-old boy accompanied by his mother for psychiatric evaluation. He was referred by his pediatrician for counseling. The mother reports that the boy has been constantly anxious and has bizarre thoughts like his mom dying or failing to pick him up from school, which leads to unwarranted worries. Besides, Dev has odd beliefs, such as his mom loving his brother more than she loves him. Dev’s habit of throwing things has gotten him in trouble at school. He reports that he is mostly anxious about a number of things. He often has terrible dreams where he gets lost or fails to find his mother and brother. Dev has been having concentration difficulties in school and gets into trouble for staring at the window.
The mother reports that the boy has problems sleeping since he insists the doors be open and sleeps with the lights on. He also frequently wakes up at night. Moreover, Dev often complains of headaches and stomach aches when at school so that he can be allowed to go home. His appetite has reduced, leading to a loss of three pounds in the past three weeks. He also experiences bedwetting, which has persisted despite being on treatment with DDVAP.
Substance Current Use: No exposure to substance use.
Medical History: No chronic illnesses.
ROS:
Objective:
Diagnostic results: No tests ordered.
Assessment:
Mental Status Examination:
The boy is neat, appropriately dressed, and appears to be his stated age. He is awake, alert, and oriented. He has a clear and coherent speech. He has a logical and coherent thought process. He expressed fear of the dark and his mother and brother being in danger. No hallucinations, obsessions, hallucinations, or suicidal thoughts were noted.
Separation Anxiety Disorder (SAD): SAD is characterized by developmentally inappropriate and unwarranted fear or anxiety regarding separation from those to whom a child is attached. This presents with: Recurrent excessive distress when expecting or experiencing separation; Persistent and unwarranted worry about losing major attachment figures; Nightmares about losing attachment figures; Constant complaints of physical symptoms; Reluctance to sleep away from home or sleep away from the attachment figures (Weeks et al., 2023). Dev reports being constantly worried about his mother and brother being in danger and often reports physical symptoms so that he can go home. He has constant worry when away from his family and has reported having distressing dreams about something bad happening to his family members.
Pediatric Generalized Anxiety Disorder (GAD): Children with GAD usually present with excessive anxiety about regular, day-to-day situations. The anxiety is usually intrusive, causing distress or functional impairment. Besides, worry or anxiety is often accompanied by physical symptoms, like sleep disturbance, muscle tension, restlessness, gastrointestinal symptoms, and chronic headaches (Klein et al., 2023). This differential diagnosis aligns with the patient’s symptoms of constant unwarranted anxiety, sleep disturbance, and complaints of stomachaches and headaches.
Specific Phobia: This is characterized by significant fear or anxiety about a specific situation or object. The situation or object usually triggers anxiety
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