Diagnosis Major Depressive Disorder
a 14-year-old Hispanic female Patient who presents today with mother for an initial psychiatric evaluation. Wt 198 lbs, BMI 37.9 Index,
• The Patient stated that she has been feeling depressed a lot more than before, and its taking over her to the point that she lays down on the bed and does not want to do anything, and sometimes, will have no energy to do anything. She stated that she does not have motivation at all, feeling depressed and no energy to do anything. This started since October 2021. She stated that she could remember that it started because of the pressure from school work because they were being overloaded with a lot of home works especially during Pandemic. She mentioned that it started first by her pulling, cutting herself on the arms and legs, though it has stopped. Current presenting symptoms: trichotillomania, no motivation, feeling of hopeless, feelings of insecurity and often does not want to take her mask off, and always putting her Jacket on, feelings of self worthlessness, low self-esteem, crying frequently, fatigue, appetite changes, insomnia ( 5 hours), social withdrawal, anhedonia. laying on bed and does not want to do anything, feeling guilt, concentration issue, anxiety and worrying a lot, racing thoughts, irritable, sad, feeling on edge, no focus. She complains of hearing voices so loud she believes were her thoughts. She is not able to sleep at night.
The Patient rated her mood at 5/10 and anxiety at 7/10 on a scale of 1-10 with 1 being the least and 10 being the worst. Alleviating factor: laying on bed. Aggravating factor: any stressful situation. She denies using any illicit drug or alcohol or smoking cigarette. She denies physical, emotional or sexual abuse. She denies SI/HI/AH/VH. Medication reconciliation done
• Home Environment: living arrangements: living with parents and 2 siblings plus uncle and auntie. , no violence in the home , no exposure to violence in the neighborhood , no smoker in the home. Education: school name: Ida B Wells Middle School, Washington DC , does not enjoy school/is bored in school , no concerns from school about learning or behavior , , goals when finishes school: Physician. Exercise: plays outside , goes to the park , spends most of the time watching TV or playing video/computer games. Activities: Denies , activities with friends and have no issues with peer pressure, no issues with bullying , no gang involvement. Suicide/Depression/Mental Health: feels stressed/anxious most of the time , low self-esteem , has friend/family member to talk to if having problems , has good anger management skills , no behavior problems at school she endorses frequent crying or depressed mood , withdrawal from family, friends or school , no issues with bullying , no history of suicidal thoughts. There was history of self-harm (i.e. cutting), but , no history of violence towards others , no history of homicidal thoughts , no history of emotional, physical or sexual abuse. Safety: feels safe at home , feels safe at school , feels safe in neighborhood (no gangs/territory groups) , uses internet and social media safely. Sleep Patterns: gets less than 8 hours of sleep, have trouble falling asleep , bedtime established , goes to bed at (time): 10:30P , no television / screens in the bedroom
Diagnosis Major Depressive Disorder
• Plan: Psychoeducation provided Supportive therapy provided Safety plan setup and encouraged Options reviewed for dealing with triggers for self-harm Appropriate sleep hygiene reviewed Healthy diet encouraged Exercise discussed Mature coping skills reviewed Medication side effects, risks, and potential interactions reviewed medication dosage, frequency, and other instructions Reviewed how long it may take for medication to work.
• Perform blood analyses, including CBC, TSH/T4, Hemoglobin A1C levels, lipid panel,
Preventative Medicine
Activity: Get involved in activities that you enjoy and are interesting to you. These activities may be related to school, after school programs, volunteering or community organizations. Try to limit watching TV or playing video games. Consider a family media plan including time for physical activity and unplugged family time. Exercise is also very important. You should get at least 60 minutes of exercise every day. Be careful when using the internet; being online is the same thing as being in public. Remember that anything you share on line you are sharing with many people and it cannot be erased. Do not meet up with strangers you connect with online. All internet use should be in public areas of the home so parents can ensure online activity is safe.. Sleep: Sleep is very important at your age and you need plenty of sleep to do well in school. You should get at least 8 hours of sleep per night. Some tips for improving your sleep include: Not watching TV/ phone or screens while going to sleep, avoid napping during the day, avoid caffeine and chocolate a couple hours before bedtime, avoid large meals right before going to bed, and establish a regular bedtime.. Mental Health: Sometimes people get angry, upset, stressed or sad about a certain situation. It is not ok to hurt yourself or others when this happens. It is also not good to use violence (ex: fighting) to solve problems. There are healthier ways to deal with your feelings. If you ever feel angry, upset or sad please talk to an adult or your doctor. You can also call the Access HelpLine at 1(888)7WE-HELP or 1-888-793-4357 at any time. Safety: Everyone should wear seatbelts while riding in a car. Younger adolescents may still need to be in booster seat, low-profile backless boosters may be more acceptable to the adolescent. Your child should continue to ride in the back seat until 13 years of age. Youth under 16y should not ride ATVs. Model safe behavior by always wearing your seat belt. Make sure your child is always wearing a helmet while riding a bike/scooter/skating etc. Use sunscreen with SPF greater than 15, reapply every 2 hours. Develop safety rules with your child such as not riding in a vehicle with someone who has been using drugs or alcohol. Guns, knives and other weapons are extremely dangerous and should not be used to fix problems. It is best not to have a firearm in your home, however if necessary firearms should be stored unloaded and locked with ammunition locked separately. Do not listen to loud music in ear buds
