Angela Cortez ihuman Case Summary, PDF

Summary of Angela Cortez Ihuman case:

Clinical Case Summary: Adolescent Depression with Academic Decline

Patient Profile: https://studyingnurse.com/wp-content/uploads/2024/09/ihumanangela.html

• 18-year-old female high school senior
• Previously strong student (3.5 GPA)
• Brought in by mother due to concerns about fatigue and mood changes

Key Presenting Issues:

1. Mental Health Symptoms:

• Persistent fatigue
• Daily crying episodes
• Social withdrawal
• Feelings of worthlessness
• Passive suicidal ideation
• Irritability
• Loss of interest in activities

1. Academic Changes:

• A significant drop in grades (from 3.5 GPA to C’s)
• Difficulty concentrating
• Decreased motivation
• Anxiety about college acceptance

1. Physical Changes:

• 25-30 pound weight gain over past year
• Poor eating habits
• Persistent fatigue despite adequate sleep

Contributing Factors:

1. Social:

• Recent breakup with boyfriend
• Social isolation
• Reduced extracurricular activities

1. Family:

• Living situation stress (sharing room with younger sister)
• Parental pressure about academics
• Family conflicts about internet usage vs. social activities

1. Environmental:

• Senior year academic pressure
• College application stress
• Social transitions

Primary Concerns:

• Depression symptoms affecting multiple life domains
• Academic performance decline
• Family relationship strain
• Social withdrawal
• Changes in physical health
• Poor coping mechanisms

Primary Diagnosis:
Major Depressive Disorder, single episode, moderate

Recommended Interventions:

1. Mental Health Support:

• Individual counseling
• Possible psychiatric evaluation
• Depression monitoring

1. Academic Support:

• School counselor involvement
• Study skills development
• Possible academic accommodations

1. Family Support:

• Family therapy consideration
• Parent education about depression
• Communication skills development

1. Lifestyle Modifications:

• Dietary counseling
• Exercise plan
• Sleep hygiene education
• Stress management techniques

This case highlights the complex interplay between mental health, academic performance, and social relationships in adolescents, emphasizing the need for a comprehensive treatment approach addressing multiple domains of functioning.

Angela Cortez Ihuman case Instructions

Angela Cortez Ihuman SOAP Note

Patient Name: Angela Cortez
Date of Service:
Provider Type: Mental Health Assessment

SUBJECTIVE

Chief Complaint

“I’m tired all the time” (brought in by mother due to fatigue, tearfulness, and academic concerns)

History of Present Illness

18-year-old female high school senior presents with:

• Fatigue and difficulty concentrating x 2 months
• Academic decline from 3.5 GPA to C grades
• Daily crying episodes
• Social withdrawal
• Weight gain of 25-30 pounds over past year
• Persistent fatigue despite reported adequate sleep
• Symptoms began around start of senior year

Mood/Depression Screening

• Depressed mood daily
• Anhedonia
• Social isolation since boyfriend breakup
• Passive suicidal ideation (“wish I could disappear”)
• No active suicidal ideation/plan
• Self-blame regarding relationship and family issues
• Irritability, especially towards family members
• Crying daily for past month

Past Medical History

• No significant medical conditions reported
• No prescription medications
• OTC: Ibuprofen PRN for menstrual cramps
• Immunizations up to date
• No known allergies

Social History

• Lives with parents and freshman sister
• Recent breakup with boyfriend
• Decreased social activities
• Single past marijuana use with ex-boyfriend
• No current substance use
• Diet: Irregular eating patterns, skips breakfast, frequent fast food
• Family tension regarding academics and internet usage
• Shares room with younger sister (source of conflict)

Review of Systems

• Constitutional: Fatigue, weight gain
• Psychiatric: Depression, anxiety, irritability
• Sleep: Reports adequate hours but non-restorative
• GI: Increased appetite
• All other systems negative or non-contributory

OBJECTIVE

Mental Status Examination

• Appearance: Tearful, slightly annoyed tone of voice
• Behavior: Cooperative but emotional during the interview
• Speech: Normal rate and rhythm
• Mood: Depressed
• Affect: Tearful, congruent with mood
• Thought Process: Linear, logical
• Thought Content: No active SI/HI, some passive death wishes
• Cognition: Alert and oriented x3
• Insight: Fair
• Judgment: Fair

Vital Signs

[To be obtained during physical examination]

ASSESSMENT

1. Major Depressive Disorder, Single Episode, Moderate (F32.1)

• Multiple neurovegetative symptoms
• Academic decline
• Social withdrawal
• No prior episodes reported

1. Academic Problems (Z55.9)

• Significant decline in academic performance
• College admission concerns

1. Parent-Child Relational Problem (Z62.820)

• Family conflict regarding academics and behavior
• Communication difficulties

1. Problems Related to Social Environment (Z60.9)

• Social withdrawal
• Recent relationship loss

PLAN

1. Mental Health Interventions:

• Refer for individual counseling/psychotherapy
• Consider psychiatric evaluation for possible medication management
• PHQ-9 screening to establish baseline depression severity
• Safety plan development
• Follow-up appointment in 1 week

1. Academic Support:

• Coordinate with school counselor
• Discuss possible academic accommodations
• Study skills assessment and support

1. Lifestyle Modifications:

• Sleep hygiene education
• Dietary counseling
• Exercise recommendations
• Stress management techniques

1. Family Support:

• Consider family therapy referral
• Parent education regarding depression
• Communication skills development

1. Laboratory Studies:

• CBC, CMP, TSH, Free T4
• Consider vitamin D level
• Consider screening for other medical causes of fatigue

1. Follow-up Plan:

• Schedule follow-up visit in 1 week
• Provide crisis hotline numbers
• Instructions for emergency care if symptoms worsen

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