Assessment and Diagnostic formulation?

Name: Rosalina

Identification: The patient is a 18-year-old Hispanic female referred to the emergency

department for evaluation by her high school guidance counselor and subsequently referred for

inpatient hospitalization.

Chief complaint: "I told my friend I was hurting myself."

History of chief complaint:

The patient told her friend at school that she had been self harming by making cuts on her

left forearm and that she wanted to die. She states she cuts herself after arguments with

her mother because it helps her to feel better.

Her mother would not let her go out with her friends and expects her to help take care of

the house and her younger siblings. Patient started to have suicidal thoughts about a

month ago, and the thoughts have been increasing in intensity since then.

She currently has a plan to overdose on over-the-counter sleep medication that her

mother keeps at home. Patient reports difficulty focusing in school and recent loss of

energy. She reports crying daily at home 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 stated that she had stopped going because insurance did not cover it anymore and her

family could not afford to pay for it. No previous psychiatric medication trials.

Medical History:

No known allergies. No acute or chronic medication problems. Regular menses. Not

using any birth control. Patient reports poor sleep and reduced appetite for the past

month. Not intentionally restricting her diet.

Height and weight are within normal limits. Superficial healing lacerations noted on left

fore

arm.

History of drug or alcohol abuse: Patient denied use of alcohol, marijuana or other illicit

substances.

Family history:

Patient's mother is from Ecuador, and her father is from Puerto Rico. The patient was

born in the United States. She lives at home with her mother and three younger siblings.

The patient's father returned to Puerto Rico about 4 years ago, and she has minimal

contact with him. Her mother works for a catering company. Patient's mother has a

history of depression treated with fluoxetine. Maternal aunt and grandmother too may

have depression. No reported psychiatric hospitalizations or family history of bipolar

disorder.

Personal History:

Perinatal: Normal full-term vaginal birth. No known complications.

Childhood: No developmental delays or learning disorders.

Adolescence: The patient states she gets mostly As and Bs in her classes at school

and does not require any special educational accommodations.

However, her grades have declined significantly in the past month. She identifies as

bisexual and denies any current intimate relationship. History of sexual activity with

both male and female peers.

Trauma/abuse history: Patient denied.

Mental Status Examination:

Appearance: Casual dress, adequate grooming and hygiene, bangs dyed blue.

Behavior and psychomotor activity: Normal gait, moderate eye contact.

Consciousness: Alert.

Orientation: Oriented to person, place and time.

Memory: Not formally tested but appeared intact during assessment.

Concentration and attention: Attention was intact during the assessment.

Visuospatial ability: Not assessed.

Abstract thought: Not formally assessed.

Intellectual functioning: Good intellectual functioning and vocabulary.

Speech and language: Quiet volume, low pressure, underproductive.

Perceptions: No evidence of perceptual disturbance. Patient denied hallucinations.

Thought processes: Logical, coherent.

Thought content: Preoccupied with anger about having to take care of her siblings.

Suicidality or homicidality: Suicidal ideation with plan to overdose on over-the-counter sleep

medication, which she has access to at home. Patient reports uncertain intent to act on this

plan.

Mood: Depressed.

Affect: Congruent with mood, constricted.

Impulse control: Poor.

Judgement/insight/reliability: poor/poor/fair.