Differential Diagnosis
The patient's presentation suggests a complex interplay of psychological, social, and potentially traumatic factors. Here's a categorized differential diagnosis:
Single most likely diagnosis
- A. Intimate partner violence: The presence of bruising on the forearms and neck in various stages of healing, combined with the patient's withdrawn behavior and recent start of a new relationship, strongly suggests intimate partner violence. The patient's inappropriate dressing for the weather (wearing a turtleneck sweater in hot temperatures) could be an attempt to conceal additional bruises.
Other Likely diagnoses
- B. Major depressive disorder: The patient's loss of interest in hobbies, recent drop in grades, and withdrawn behavior are all consistent with major depressive disorder. However, the presence of physical bruises and the specific context of the new relationship make intimate partner violence a more pressing concern.
- E. Self-injury disorder: Although less likely given the context, self-injury could be considered, especially if the patient's behavior and bruises were not adequately explained by other factors. However, the pattern of bruising and the patient's overall presentation more strongly suggest external trauma rather than self-inflicted injury.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- D. Polysubstance use disorder: While the patient's use of marijuana and alcohol is mentioned, there's no clear indication that this is the primary issue. However, substance use disorders can lead to significant morbidity and mortality, and it's crucial to assess for potential substance-related problems, especially if the patient's situation doesn't improve with addressing the more apparent issues.
- Human trafficking or exploitation: Although not listed among the options, it's essential to consider the broader context of potential exploitation, especially given the patient's age, the age difference with the partner, and the signs of physical abuse.
Rare diagnoses
- C. Oppositional defiant disorder: This diagnosis seems less relevant given the patient's age and the specific context of the presentation. Oppositional defiant disorder is more commonly considered in pediatric populations and doesn't directly explain the physical findings or the patient's current situation.
- Factitious disorder or Munchausen syndrome: These conditions involve the fabrication or induction of illness in oneself to gain attention and sympathy. While they are rare and might not be the first consideration, they should be kept in mind if the patient's story and physical findings don't align well with other diagnoses, or if there are inconsistencies in the patient's history or behavior over time.