Week 6 Assignment 1 Mental Health Clinical Presentation

Mental Health Clinical Presentation SUBJECTIVE DATA: CC: “Patient wants to be left alone all the time and is very moody” HPI: J.D, a 16 year-old male presents to the clinic accompanied by his mother. The mother reports that since the death of the patient’s father in a road accident two months ago, the patient has not been himself. He no longer interacts with his friends or even his family. He has since stopped being active in the school soccer club which he is a member. The patient is very moody and gets irritated quickly when bothered by anyone. He now likes to stay alone. Mother reports that the patient has complained of lack of sleep or inability to stay asleep for long which makes him feel low of energy in the morning which is contributing to him missing a lot of school days. Mother also reports that his academic performance is slowly declining. In addition, the patient barely touches his food which has led to significant weight loss. When asked about how he feels he states that he feels empty and misses his dad. He also states that sometimes he wishes he could die so he can go see his father. The patient describes his father as his best friend and a good man and he doesn’t understand why he left him. Current Medications: None Allergies: No Known Allergies Immunization: Up-to-date with all vaccinations Past medical history: Suffered moderate anxiety at 12 years when he was moved to another school which was treated through psychotherapy for 3 months. Past surgical history: None Family History: Father: depression and died from car accident due to driving while drunk. Mother: None Social History: Patient is a student, lives with his mother alone. Has few friends and socializes moderately. Plays soccer and is a member of the school soccer team. Denies the use of tobacco, alcohol, and other illicit drugs. Developmental history: Mother reports no delays Review of Systems (ROS) Constitutional: denies fever, chills, night sweats, dizziness, nausea, and