UEM1 Task 1: Diagnose Mental Conditions in Children and Adolescents Across Care Settings

UEM1 Task 1: Diagnose Mental Conditions in Children and Adolescents Across Care Settings

UEM1 Task 1 D347 Patient Case Studies

D347 Patient Case Studies

For Task 1 of D347, you must use the case study that corresponds to the first initial of your last name, as follows:  

Last Name	Case Study	Pages
A-C	Case Study 1	pg. 2-3
D-G	Case Study 2	pg. 4-5
H-L	Case Study 3	pg. 6-7
M-R	Case Study 4	pg. 8-9
S-Z	Case Study 5	pg. 10-11

Case Study 1

Patient Name: Michael Brooks

Gender: Male

Date of Birth: 12/01/## (The patient is 7 years old)

Identifying Information: Michael was a 7-year-old black male that appeared stated age. He was well-groomed, appropriately dressed, and well-nourished with clean clothes. He was awake, alert, friendly, with good eye contact and cooperative. He was easily distracted and demonstrated high levels of psychomotor activity (fidgeting, squirming, getting up during interview). He demonstrated age-appropriate bonding with mom. 

Chief Complaint: “We wanted him evaluated because he struggles to get his homework and chores done and is frequently getting in trouble in school.”

History of Present Illness: Mom stated that Michael has experienced problems with focus, concentration, hyperactivity, impulsivity, and misbehaving that she first noticed at the age of 2. When asked what caused his symptoms, Michael shrugged. He stated, “I don’t know why I can’t listen. Sometimes I forget.” He stated that he tries to behave and doesn’t break rules on purpose but is always getting in trouble. Mom denied disrespectful behavior such as talking back and hitting or hurting others, but she did state that Michael misbehaved by not following through on what is asked of him at home and at school, and he had been sent to the principal’s office twice in the past few months for being disruptive in class and not sitting down when asked. Per mom, Michael experiences a harder time listening when he must do things that take too long or if he sees or hears something that redirects his attention. He complained of boredom in class, especially during lessons, and boredom leads to situations in which he gets in trouble with her teacher for “talking to my friends, getting out of chair and walking around, or talking over people.”  

Michael stated that he can focus and concentrate when engaging in activities he enjoys, such as football. His coach stated that Michael is fast and highly competitive. He plays well, but the coach does find himself having to frequently redirect Michael when explaining skills. Mom indicated that he loses his temper with his sister and frequently argues with her. His sister acts like his second mom and tries to help Michael by reminding him to get his chores and homework done, and it bothers him. He doesn’t lose his temper with his friends, and his teachers have never mentioned him having a short temper at school.  

Mom denied any history of treatment for his symptoms and just thought he was a high-energy child. Mom brought patient in after the school recommended that Michael receive a professional evaluation. 

Medications/Drug Allergies: Denied any current medications and drug allergies.

Psychiatric History: Denied history of mental health diagnoses, psychiatric hospitalizations, or therapy.

Substance Use: Denied current or past use of illicit, controlled substance, and alcohol use. 

Social History: The client is a 2nd grader in elementary school. He lives with his mom and one sibling (sister), age 12. He has friends on the football team and denied any problems with bullying or legal issues. Mom works as a certified nursing assistant.

Medical History: The patient denied medical history. His last physical examination was a year ago, and per mom, findings were within normal limits.

Neurodevelopmental History: He was born at 40 weeks, with no delivery complications, and met all developmental milestones with no history of learning disabilities.

Medical Review of Systems: All ROS normal.

Psychiatric Family History: Denied any family history of mental health problems.

Mental Status Examination: Michael appears stated age. He was well-groomed and appropriately dressed, and well-nourished with clean clothes. He was awake, alert, friendly, with good eye contact, and cooperative. He was easily distracted and demonstrated hyperactivity (fidgeting, squirming, getting up) throughout the interview/ He demonstrated age-appropriate bonding with mom. His speech was clear, normal rate, flow, and tone, and normal for his age. His mood was euthymic and affect congruent. His thought processes were moderately distracted and demonstrated a hard time maintaining focus throughout the interview. 

His thought content was appropriate for his developmental age. He denied thoughts of SI/HI. Denies delusions or hallucinations. Michael was awake, alert, and oriented to person, place, time, and situation. He had trouble focusing and concentrating during exam. He demonstrated some challenges with both short-term and long-term memory. Per mom, patient is of above-average intelligence and has performed well in school when activities or assignments are short. He has normal abstract reasoning skills. His insight and judgment are fair. 

Physical Exam

Vital Signs:

• Blood Pressure: 98/64
• Heart Rate: 82
• Respirations: 16

Height: 4’2″

Weight: 51 pounds

Labs/Diagnostics: (per primary medical records)

• Blood Tests: Within Normal Limits 
• EKG: Within Normal Limits 

Case Study 2

Patient Name: Macy Wilson

Gender: Female

Date of Birth: 04/15/20## (The patient is 16 years old)

Identifying Information: Macy is a 15-year-old female who lives with her mother, father, and 18-year-old brother. She is a sophomore in high school. She was referred by her primary doctor for concerns with her body and self-image. She is accompanied by her mother.

Chief Complaint: Per mom, “We are worried about her health and obsession with diet and exercise.”  

Per patient, “I have been trying to get healthy by improving my diet and exercise routine.” 

History of Present Illness: Mom was interviewed separately. Per mom, Macy became increasingly obsessed with diet and exercise routine over the past 6 months. She auditioned for her high school cheerleading team and was assigned a base position. She originally wanted a flyer position but was told that they needed her in base since she was “bigger and stronger” than the smaller girls on the squad. At the time, she was 5’4” and 125 pounds. Initially, Macy was engaging in what the mother considered to be a healthy routine of diet and exercise. She was exercising 1 hour per day, 3 days per week, in addition to her 1 hour after school cheerleading practice and eating 3 healthy meals per day. Two months into her exercise routine, she weighed 110 pounds. She was receiving compliments from her friends and some family members, which increased her diet efforts. She started journaling calories and was fixated on maintaining her caloric intake to less than 900 calories per day. Her exercise routine increased to 7 days per week, 90 minutes per day, in addition to her cheer practices. Her mother later discovered that Macy was not eating lunch at school. Five months into her exercise routine, Macy weighed 98 pounds, and her mother became concerned when Macy was no longer menstruating. She was avoiding eating meals with family and, when forced to eat with family, was restricting certain foods from her diet. She was evaluated by her primary doctor and diagnosed with anemia and referred to the clinic for a mental health evaluation. Macy does not have a history of eating disorders. 

Macy states that she started exercising because she felt that being a base meant that she was “too big” for any other position on the cheerleading team. She compared herself to the team members who are flyers and felt that they were much smaller than she was. She felt that she was disciplined and was proud of her results, so she continued to “improve” her diet efforts. She did express an extreme fear of gaining weight and felt that she needed to closely monitor her diet by recording her calories and progress. She did become concerned when she stopped menstruating 1 month ago. Her primary doctor explained why she was experiencing amenorrhea and the long-term complications with excessive diet and exercise. Macy stated that looking in the mirror or weighing herself made her feel “fat” and motivated her to continue her dietary efforts. After learning how her symptoms were directly attributed to her diet, she recognized she had a problem. For the past week, she has been following treatment recommendations set forth by her primary. She is currently taking iron pills and multivitamins for her anemia. Her parents have also restricted her exercise routine from 7 days a week to 5 days per week, and they are monitoring her meals to ensure she is eating 3 healthy meals per day. She denies any purging behaviors. She has also recognized that she has been excessively worrying for over 7 months, and the recent modifications to her diet have increased her anxiety levels. She is experiencing insomnia and stomachaches prior to mealtimes. Her mom has removed all scales to avoid Macy from weighing herself. 

Medications/Drug Allergies: Iron supplement pill 1 tab by mouth daily; Multivitamin pill 1 tablet by mouth daily. NKDA.

Psychiatric History: History of GAD diagnosed at the age of 11. At the time, Macy would excessively worry about her grades. After a year of therapy, she was discharged from care as she was demonstrating effective coping skills. 

Substance Use: Denies current or past illicit substances or alcohol use.

Social History: She is a sophomore in high school. She lives at home with parents and her 18-year-old brother, who is currently attending a local community college. She has several close friendships on her cheer squad and is not in a romantic relationship. She denies being sexually active.

Medical History: Most recent physical completed 2 weeks ago. She was diagnosed with iron deficiency anemia.

Neurodevelopmental History: She was born at term, with no delivery complications, and has met all developmental milestones with no history of learning disabilities.

Medical Review of Systems: She complained of low energy levels, fatigue, and amenorrhea secondary to anemia diagnosis. Is currently being treated by primary doctor for anemia.

Psychiatric Family History: Mom has a history of GAD.

Mental Status Examination: Macy appears stated age. She is well-groomed and appropriately dressed in clean clothes. She appears malnourished. She is awake, alert, with fair eye contact with occasional periods of nervousness when asked about her eating patterns. She is cooperative and a reliable historian. Her speech is clear, normal rate, flow, and tone and normal for her age and orientation with occasional pauses mid-sentence when asked about her diet. She describes her mood as nervous, and affect is congruent. Her thought processes are linear and goal-directed. She recognizes that she has lost control of her diet and needs help. Her thought content includes ruminations and obsessions over food and diet. She denies any current thoughts of SI/HI, delusions, or hallucinations. Macy is awake, alert, and oriented to person, place, time, and situation. Executive functioning appears intact. She demonstrates good short-term and long-term memory and fair abstract reasoning skills. Macy has fair insight and demonstrates fair judgment.  

Physical Exam

Vital Signs:

• Blood Pressure: 92/58
• Heart Rate: 89
• Respirations: 16

Height: 5’4″

Weight: 100 pounds (BMI: 17.2)

Labs/Diagnostics: (per primary medical records)

• Lab: Positive for anemia. Chemistry within acceptable limits.  
• EKG: Within normal limits 
• Urine Toxicology: Negative 
• Urine Pregnancy: Negative

Case Study 3

Patient Name: Jordan Nguyen

Gender: Male

Date of Birth: 01/31/20## (The patient is 5 years old)

Identifying Information: Jordan, a 5-year-old boy, living with both parents and a 10-year-old sister. 

Chief Complaint: Jordan’s parents were referred to your outpatient clinic by their pediatrician for concerns with aggression and problems with socialization. Per mom, “He is having difficulty transitioning to school life. He is frequently getting in trouble for his behavior and not getting along with peers.”

History of Present Illness: Jordan’s behaviors were readily apparent to both parents since early childhood. He was a baby who rarely smiled and showed minimal interest interacting with parents and sister. He did not look at family when babbling during his first year of life and, to this day, does not maintain good eye contact or interest in socializing with others. His mother stated that he did experience minor delays in crawling, walking, and speaking. Initially, his parents believed that his behaviors were due to him being the baby of the family. His sister met milestones earlier than other children, so the parents also felt that they may have had a skewed perception of what is considered normal for developmental age. He does not respond well to change and has frequently experienced meltdowns when his routine is changed.  

The parents noticed that he has never had interest in playing with other kids. They understood that young children tend to lateral play but started becoming concerned when this lack of interest persisted to this day. There are several neighborhood children his age that play outdoors, and Jordan has no interest in playing with them. His parents felt that this behavior would change once he started school, but this lack of interest in socializing with other kids has persisted. He is in a kindergarten class, and his teachers have reached out to his parents due to him acting aggressively toward other children and experiencing meltdowns when made to share or take turns at school. He demonstrated interest in playing with blocks and sorting his blocks by color since the age of 2 and has always demonstrated compulsive and rigid behaviors since an early age. If anyone moves or touches his toys, he has a meltdown. 

Medications/Drug Allergies: Denied any current medications and denies drug allergies.

Psychiatric History: Denied history of mental health diagnoses, psychiatric hospitalizations, or therapy.

Substance Use: Denied current or past use of illicit, controlled substance, and alcohol use.

Social History: Jordan’s parents are both educated professionals. His mother is a corporate attorney, and his father is an electrical engineer. His mother gave birth to Jordan at the age of 42, and his father was 46. 

Medical History: Denied medical history. His pediatrician evaluated him a couple of weeks ago and suspected neurodevelopmental delays.

Neurodevelopmental History: He was born at 40 weeks, with no delivery complications. No problems were noted during early infancy. He walked at 12 months and began using single words between 24-48 months. His speech was grammatically correct but spoke in a stilted quality. He has received psychoeducational assessments and has always tested in superior-to-gifted range. However, he has always struggled with behavioral problems.

Medical Review of Systems: All ROS normal.

Psychiatric Family History: Denies any family history of mental health problems.

Mental Status Examination: Jordan was a properly groomed, well-nourished 5-year-old boy. He demonstrated minimal interest in answering questions and maintained minimal eye contact. He proceeded to talk about his interest in dinosaurs and asked what the interviewer’s favorite dinosaur is. Once the interviewer responded tyrannosaurus rex, Jordan shared extensive facts about t-rexes. His engagement and eye contact increased during this time. When asked about friends, Jordan did not respond and instead shrugged. His facial expressions were limited, and he did not describe his feelings when asked. He denied any feelings of wanting to hurt himself or others. When asked about aggressiveness towards peers at school, he mentioned that a peer touched his dinosaur that he had on his desk. He denied hearing voices or seeing things that were not there. His mother and father denied observing him respond to internal stimuli. 

Physical Exam

Vital Signs:

• Blood Pressure: 93/67
• Heart Rate: 73
• Respirations: 19

Height: 3’7″

Weight: 41 pounds

Labs/Diagnostics: (per primary medical records)

• Blood Tests: Within Normal Limits 
• EKG: Within Normal Limits 

Case Study 4

Patient Name: Mario Hernandez

Gender: Male

Date of Birth: 11/01/20## (The patient is 8 years old)

Identifying Information: Mario is an 8-year-old Hispanic male that appears stated age. He was well-groomed, appropriately dressed, and well-nourished with clean clothes. He was awake, alert, shy, with poor eye contact, but cooperative. He demonstrated psychomotor agitation and frequently looked down at hands and wringed hands. He was accompanied by his mother. 

Chief Complaint: “I am having trouble falling asleep at night” 

History of Present Illness: Per mom and client, he has experienced excessive worrying, insomnia, and stomachaches for the last 9 months. His mother scheduled a visit with his pediatrician for symptoms and was referred for a mental health evaluation after labs and diagnostics found no medical cause for symptoms. When asked if anything was causing him to worry, Mario shrugged and looked down at hands. Mom stated that he worries about things such as school, family, health, and exams. Mario stated that exams, presentations, and bedtime increase nervousness and overthinking. Anxiety is reduced when engaging in activities such as reading. His mom also mentioned that his anxiety wasn’t noticeable during summer break. When he was on summer break, Mom denied any history of treatment for his symptoms. Received full medical workup due to stomachaches, but tests came back negative for any medically related causes. 

Medications/Drug Allergies: Denied any current medications and denies drug allergies.

Psychiatric History: Denied history of mental health diagnoses, psychiatric hospitalizations, or therapy.

Substance Use: Denied current or past use of illicit, controlled substance, and alcohol use.

Social History: The client is a 2nd grader in elementary school. He lives with mom, dad, and one sibling, age 5. He has several close friends and denied any problems with bullying and any history of legal problems. Mom and dad have a strong relationship and avoid arguments in front of children. Mom is a supermarket clerk, and dad is a trucker.

Medical History: Denied medical history. His last pediatric examination was a couple of weeks ago, and per mom, findings were within normal limits.

Neurodevelopmental History: He was born at 40 weeks, with no delivery complications, and met all developmental milestones with no history of learning disabilities.

Medical Review of Systems: All ROS normal except for stomachaches caused by emotional triggers.

Psychiatric Family History: Mom has a history of MDD and GAD. She had attended psychotherapy to help with symptoms.

Mental Status Examination:

Mario appeared stated age. He was well-groomed and appropriately dressed, and well-nourished with clean clothes. He was awake, alert, friendly, poor eye contact, and cooperative. He demonstrated psychomotor agitation and frequently looked down at hands and was wringing his hands throughout the interview. His speech was soft and low tone. Speech became rapid when speaking about emotional triggers. His mood was nervous and affect congruent. His thought processes were linear and goal-directed. Speech became pressured when talking about tests, exams, pandemic. His thought content included frequent ruminations-worrying about the future, pandemic, family health, school, and grades. He denied thoughts of SI/HI. Executive functioning appears intact. He demonstrated no challenges with both short-term and long-term memory. Per mom, patient is of above-average intelligence and has performed well in school. He has normal abstract reasoning skills. He demonstrated fair insight and judgement. 

Physical Exam

Vital Signs:

• Blood Pressure: 92/56
• Heart Rate: 68
• Respirations: 18

Height: 4’7″

Weight: 56 pounds

Recent Labs/Diagnostics: (per primary medical records)

• Blood Tests: Within Normal Limits 
• EKG: Within Normal Limits 
• Abdominal x-ray-no abnormalities 
• UA-negative for UTI 

Case Study 5

Patient Name: Kayla Richardson

Gender: Female

Date of Birth: 08/23/20## (The patient is 16 years old)

Identifying Information: Kayla Richardson is a 16-year-old adolescent that arrived at the clinic with mom.

Chief Complaint: “I have been feeling depressed with thoughts of wanting to die.”

History of Present Illness: Kayla is a 16-year-old female who was brought in by her mother due to feelings of sadness, suicidal ideation, and opioid use for the last month. She is a sophomore at a private school. Her parents are divorced, and her father moved to Australia 6 years ago. She is an only child and lives with her mother. Her mother works in marketing and frequently works 50-hour work weeks. According to Kayla, she started using pain pills after her friend gave her one 6 months ago. Initially, she was taking a pill 1-2 times per week, but her intake had increased to 3-5 Lortab pills per day after 2 months of using. She was purchasing the pills from acquaintances at school and online. Mother was called to Kayla’s school after she was found to be under the influence. Her mother sent her to rehab for 3 weeks, and Kayla stopped using and has been attending psychotherapy and family therapy since discharge but stopped attending therapy 3 weeks ago. 

Kayla started using prescription pills 3 weeks ago after experiencing feelings of sadness, hopelessness, worthlessness, and guilt 1 month ago. She stopped attending her after-school activities and has lost interest in spending time with her best friend. She recognized that she had a problem, so she confided in her mother that she was buying Lortabs from acquaintances and her feelings of depression and thoughts of suicide. She is currently using 1–3 Lortab pills per day. She is experiencing insomnia, loss of appetite with a 10-pound unintended weight loss and low energy levels. She has thoughts of death but denies any attempts or current plans. Her last use was 3 days ago.   

Medications/Drug Allergies: None, NKDA

Psychiatric History: Opioid use

Substance Use: History of marijuana use 2-3 times 1 year ago. Use of Lortab 1–3 per day for 3 weeks. Last use 3 days ago.

Social History: She is a high school sophomore living with mom. Dad lives out of country, and she has limited communication with him since he moved 6 years ago. She is an honor roll student but has recently experienced a drop in grades (past 3 weeks) due to missing assignments. She has 3 close friends and is currently not in a relationship. She denied being sexually active.

Medical History: Denied 

Neurodevelopmental History: She was born at term, with no delivery complications, and has met all developmental milestones with no history of learning disabilities.

Medical Review of Systems: All ROS normal.

Psychiatric Family History: Mom has history of MDD. Per mom, dad has a drinking problem.

Mental Status Examination: Kayla presented as a disheveled, poorly groomed, and malnourished 14-year-old adolescent that looked stated age. She appeared sad and tearful, with poor eye contact throughout the interview. She was cooperative. She described her mood as sad, and her affect is congruent. Her speech was low volume. Her thought processes were logical and goal-directed. She recognized that she is experiencing emotional problems and wants treatment before she becomes highly addicted to opioids. There was no evidence of thought blocking, insertion, or deletion, or ideas of reference. No perceptual abnormalities were noted. She has experienced thoughts of suicide. She denies any intent of self-harming and describes her thoughts as wanting to go to sleep and not wake up. She demonstrated poor attention and concentration and has good short-term and long-term memory. 

Physical Exam

Vital Signs:

• Blood Pressure: 104/64
• Heart Rate: 81
• Respirations: 15

Height: 5’6″

Weight: 115 pounds

Labs/Diagnostics: (per primary medical records labs 6 months ago) 

• Lab: Within acceptable limits  
• EKG: Within normal limits 
• Urine Toxicology: Positive for opioids 
• Urine Pregnancy: Negative 

UEM1 Task 1: Diagnose Mental Conditions in Children and Adolescents Across Care Settings