Case Study:

Identification: Patient is a 16 yr. old Hispanic female referred to the emergency department for evaluation by her school guidance counselor and admitted to the inpatient unit.

Chief Complaint:Patient states "I told my friend I was hurting myself."

The patient told her friend at school that she had been self-harming by making cuts on her left forearm and that she wants to die. She states she cuts herself after arguments with her mother because it makes her feel better. Her mother would not let her go out with her friends and expects her to complete chores at home and take care of her younger siblings. Patient started having suicidal thoughts approximately one month ago, these thoughts have become more intense since that time. Patient has a plan to overdose on over-the-counter sleep medications that she found in the family medicine cabinet. Patient reports having difficulty focusing at school and recent loss of energy. She reports crying daily and denies history of symptoms of mania or hypomania.

Past Psychiatric History-No previous psychiatric hospitalizations. Patient was in outpatient therapy about 6 months ago because of depression and anxiety. She states she stopped going because her insurance wouldn't cover it and family could not afford it. She has never been prescribed psychiatric medications.

Medical History- No known allergies. denies acute or chronic medical problems. Menses regular; not on birth control. Patient reports sleep poor and appetite poor over the past month. States she is not restricting her diet Height/weight within normal limits. Superficial lacerations noted on left forearm, healing.

Patient denies history of alcohol, marijuana, or other drug use.

Family history- Patient's mother is from Ecuador and her father is from Puerto Rico. Patient was born in US. Patient lives with her mother and three younger siblings. The patient's father returned to Puerto Rico 4 years ago, she has minimal contact with him. Mother reports history of depression, treated with fluoxetine. Maternal aunt and grandmother also diagnosed with depression. Mom works as a waitress. Mom reports no psychiatric hospitalizations or family history of bipolar disorder.

Patient was normal full term vaginal birth without known complications.

No identified developmental delays or learning disorders.

Patient states she gets mostly As and Bs at school without educational accommodations however her grades have declined significantly over the past month. Patient identifies as bisexual and denies any current intimate relationship. History of sexual activity with both males and female peers.

Deniessexual abuse/trauma

Mental status exam- dress is casual, adequate grooming and hygiene, hair dyed green. Gait is normal, with moderate eye contact.

Alert, oriented to person, place time

Memory/concentration/attention-intact during interview

Speech- quiet volume, low pressure, under-productive.

Denies hallucinations/perceptual disturbance

Thought process/content- logical, coherent preoccupied with anger about having to care for siblings

Suicidal/homicidal- suicidal ideation with plan to overdose on OTC sleep medications with access to medications at home. Patient reports she was uncertain regarding intent to act on plan.

Mood-depressed affect- congruent with mood, constricted

Impulse controlpoor

Judgement/poor, insight/poor reliability/fair

After reading the case study, answer the following questions:

1. Which diagnosis (or diagnoses) will you consider for your patient?
2. Please give a rationale for your diagnosis.
3. Does your patient have any "conditions" to be considered?
4. What test or assessment tools would you administer to help confirm your diagnosis?

5. What differential diagnosis (or diagnoses) would you consider for this patient?

6.Treatment and rationale?

Identify the psychopharmacology you would select for this patient.

Please include medication class, initial dose, FDA-approved or off-label (?), and how you would titrate the dose if indicated.

7.Treatment and rationale?

Please identify the diagnostic tests you order, if indicated. (no deduction if none is indicated!)

8.Treatment and rationale?

What type of psychotherapy is indicated for this patient? What is the desired outcome of therapy?

9.Treatment and rationale?

Psychoeducation: How will you educate your patient and parents on treatment's risks/benefits/side effects?

10.What would you include in your clinical note specific to this patient?