solved

Larry is a 14 y.o. who presents to your clinic with his mother, Susan, for his third HPV vaccine. While he is waiting for his immunization, Susan pulls you aside and confides that she is extremely worried that “something is very wrong” with Larry. Over the past couple of months, his behavior has changed and become unpredictable. Always a good student, he almost failed the last grading period. During a parent-teacher conference, his teachers said that he often has difficulty “staying on task” and is disruptive, wanting to be heard in all discussions and is “dogmatic” in stressing that his ideas are always right. Susan says that he is often awake most of the night and “is never still.” However, some days he can suddenly become very sullen and quiet, withdrawing to his room and showing an “absolute lack of interest” in family or friends. He is the second of three children and has always been pleasant. She asks for you to assess him.
You talk to Larry privately in an exam room, indicating you need to listen to his heart and lungs since he is receiving his final vaccination. You ask how things are going and mention that when you asked his mother the same question, she said he was not doing as well as in the past. He immediately begins to share that he is just not challenged and is quite animated in his defense of his role in his poor grades, explaining how it is obvious he is smarter than the others in the class. He denies having mood swings, periods of depression related to his academic change, overreaction to events, or other emotional changes. He admits that he was “real down” at first because of frustration over having to be in a class where he could not achieve his full potential and his parents worry about it, but after a few days, he got over it. In response to questions about potential influences on his grades, he says he sleeps less than before but is able to function on less sleep. He denies using prescription or recreational drugs.
Past Medical History
Negative for chronic conditions
Mononucleosis (2 years ago)
Frequent bouts of otitis media as a younger child
No over-the-counter or prescription medications
Family History
Father, depression
Mother, lupus, diabetes, hypothyroidism
Grandfathers, heart disease
Physical Examination
Vital signs: T 98.4, HR 76, BP 96/58, HT 66, WT 100 lbs.
What three conditions would be considered in your differential diagnosis, with most likely condition listed first (with rationale).
What further history, further examination, and diagnostic studies are warranted to explore your differential diagnosis?

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