Submitted By bsngirl2012
Reason for Admission On 4/12/11 A.G., a 16 year old Hispanic American female voluntarily admitted herself to Aurora Behavioral Health Care (ABHC) due worsening depression and suicidal ideation. Pt stated that she had been feeling depressed for the last six months but felt as if her depression was worse now than ever. Upon admission pt was thinking seriously of acting on her thoughts of suicide by overdoing on sleeping pills or by cutting herself. For the past few months the patient had been seeing a therapist and psychiatrist but feels like they cannot fix her depression. Major stressors upon admission include lack of support from family and friends, and doing poorly in school. For the past six months A.G. had been taking 100 mg of Zoloft and 2.5 mg of Abilify for depression. A.G.’s diagnostic and statistical manual of mental disorders (DSM) was Axis I: Major Depression, single episode, and severe, Axis II: deferred, Axis III: No diagnosis, Axis IV: Moderate, And Axis V: 30/60.
Summary of Mental Status Exam
During the time of assessment A.G. appearance was neat and her attitude was cooperative but she seemed depressed during the initial assessment. The patient’s speech was normal and she had a calm demeanor. She reported feelings of being anxious ever since she was admitted to Aurora because she felt as if her depression was “not getting any better”, and that she was afraid that her medications were not working. She reported having a panic attack one month ago due to stress from school. When experiencing the panic attack she stated, “ I became very flush and could feel my heart racing extremely fast.” While she was having the attack the patient stated that she did not know what to do or how to make the panic attack stop so she tried to relax by sitting down outside where she waited for the panic attack to subside. A.G. denied any additional panic attacks since...