Case 10

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South University, Savannah *

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MN662

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Psychology

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Apr 3, 2024

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docx

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Typhon Case # 10 ID 6994-20190214-004 CHILD/ADOLESCENT PSYCHIATRIC ASSESSMENT Demographic Information : Name (Initials): A.G Age: 16 Gender: Female Race: White Ethnicity/Culture: Hispanic Religion: Catholic Adopted Child: No Living conditions: Lives in an duplex with her parents and her sister Parental employment: Mother is a housewife; Father works fulltime Family Structure (number of people living in the house): 4 Subjective: Chief Complaint/Reason for visit : "I came to see my doctor for follow up on my eating problems." History of Present Illness (HPI) : Client is a 16 years old Hispanic female who came to the office accompanied by her mother for follow up on her anorexia and depressive disorder. The client was diagnosed with a Major Depressive Disorder and Anorexia at the age of 14. She has been receiving psychiatric and therapy services at this office for the past year. She is prescribed with Celexa 20 mg orally daily. Last time seen at this office was last month and was provided with a refill for her medication. Reports feeling less depressed, better affect reactivity, improved appetite. She has gained 3 pounds in the past two months. No previous psychiatric hospitalizations. Client denies a history of abuse or traumatic events or any exposure to stressful life situations. Denies sleep irregularities. Denies suicidal/ homicidal ideation, plan or intention. Able to contract for her safety and the safety of others. Family History : Mother (34): Alive/Healthy Father (40): Alive/ Healthy Siblings (1): 1- Sister (8)/Healthy Maternal Grandparents: Grandmother-Deceased/Lung cancer, Grandfather-Deceased/Stroke Paternal Grandparents: Grandmother-Deceased/MVA, Grandfather (63)/HTN Three Generation Family: No record of suicide, mental illness, substance abuse, or criminal history Developmental History : Pregnancy Length: Full-term/ 40 weeks Medications or substances used during pregnancy: No Complications of pregnancy or delivery: Denies Client’s weight at birth: Normal/ 6.2 pounds Client’s complications during and after delivery: Denies She was able to smile at around the age of 1.5 months

She was able to sit by herself (without help) at around the age of 5 months She was able to walk by herself (without holding on) at around the age of 16 months Developed the ability to say her first word at around the age of 12 months Developed the ability to say short sentences (such as “go bye-bye”) at around the age of 16 months Client’s trouble learning to speak: No Differences from sister or other children: No Client reached her toilet training when he was 18 months old. The client learned to: -ride a tricycle at the age of 4 years -ride a bicycle without training wheels at the age of 5 years Developed the ability to get dressed by herself at the age of 5 years Developed the ability to tie the shoelaces at the age of 5 years The adolescent prefers to use: Left hand, and it was noticed by her parents when she was five years old. Mother denies significant delays during the client’s development years. Social : Current grade: 11 th grade. She has not repeated any grade or has received any special education classes. The client has never been suspended or expelled from school or has been bullied by peers. The client has never been a victim of abuse or has ever been arrested. Mother reports no firearms or any other lethal weapon at home. Child’s Playing Preferences: Chats on the internet or text with friends at home. Parent-Child Relationship: Healthy and positive relationship with both parents. Relationship with siblings: Healthy and positive relationship with her sister. Current/Past History of Domestic Violence: Denies Family Structure and Functioning: Appropriate interaction among family members. All children attend school, mother is a housewife, and father works full time. No economical stressors Degree of Parental Distress: None. Current and Past History of Emotional and/or Behavioral Problems : Gained 3 pounds in the last two months, better appetite, improved self-esteem, more interested and motivated (-) suicidality Substance Abuse : Denies alcohol or tobacco use, or the use of any other illegal drug. History of Potentially Stressful Life Events : Denies Medical History : Denies Past Psychiatric History : D iagnosed with a Major Depressive Disorder and Anorexia at the age of 14. She has been receiving psychiatric and therapy services at this office for the past year.

Prescribed with Celexa 20 mg orally daily. Last time seen at this office was last month and was provided with a refill for her medication. Allergies/Intolerances : Penicillin/ Skin rash-Hives Past and Current Medications : Medications currently taken by the child: Celexa 20 mg orally daily Medications the child has taken in the past: None Review of Systems (ROS) : Negative: No significant weight changes; no fever, chills or night sweats; no vision or hearing changes; no swallowing difficulties; no headache, chest pain or shortness of breath; no abdominal pain or discomfort; no changes on bowel movement or urination; no neck, back or muscle pain; no assistance with ambulation needed. Denies suicidal or homicidal ideation, plan or intention. No perceptual disturbances. Positive : Improved appetite, gained 3 pounbds in two months, less depressed, more interested and motivated, less concerned about body weight. Objective Exam : Vital Signs : BP (sitting position): 122/74, a pulse is 70. Height is 5'6 (170.68 cm). Weight is 120 pounds. BMI is 19.37. Constitutional : APPEARANCE AND GENERAL BEHAVIOR: A well-nourished Hispanic female who appears appropriate for her chronological age. Well-groomed and appropriately dressed, sitting upright in the chair, able to maintain eye contact, cooperative throughout the interview process. Neurological : Patient has steady gait and station, normal muscle strength and tone. Psychiatric/ Mental Status Exam : LEVEL OF CONSCIOUSNESS: Fully awake, alert, oriented and attentive. ORIENTATION: alert and oriented to person, time, place and situation (x4) SPEECH AND MOTOR ACTIVITY: Spontaneous and coherent speech, future-oriented, with normal rate and rhythm. Normal psychomotor activity, no tics or involuntary movements. MOOD AND AFFECT: Normal. The mood is euphoric, with appropriate affect reactivity and congruent with assessed mood. THOUGHT AND PERCEPTIONS: -THOUGHT PROCESS: clear, logical, organized, connected and goal-directed. Negative for disorganized speech, loose of association or thought blocking. -THOUGHT CONTENT: Negative for perceptual disturbances (hallucinations), delusions, obsessions, compulsions, or guilt, negative for hopelessness and helplessness. Self-esteem is preserved. SUICIDE/HOMICIDE: Negative for suicidal or homicidal ideations ATTITUDE: Optimistic INSIGHT: Good.

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