Demographics:
Patient 001 is a 16 years old Caucasian female who comes in today with her mother for a comprehensive mental health evaluation.
Recent Travel Outside U.S. - Recent Exposure to illnesses:
Patient denies any recent travels outside the United States.
Chief Complaint:
She complained of having self-harming thoughts and seems to cut her legs with scissors whenever she gets frustrated.
History of Present Illness:
She reports that she cuts herself at least once a week, waits for it to heal and then cut herself again. She cuts herself when she feels alone or frustrated. She reports feeling guilty when she is done cutting and cleaning herself up. The patient illustrates that she frequently feels nervous and cuts herself as punishment. Her anxiety depends on what she is doing, especially when she gets nervous. When anxious, she sweats a lot with shaky hands, heart racing and the feeling to throw up. The patient is occasionally afraid of being left alone and reports feeling uncomfortable around people she is not familiar with. She denies any history of obsessional or ritualistic behavior. She admits to having a good relationship with parents, but reports that she is occasionally hesitant to talk to her parents and denies separation anxiety. She admits to being self-aware, but denies feeling of paranoia. …show more content…
The patient admitted to feeling nervous, anxious, or on edge sometimes. She denies having any difficulty controlling her worries, but admitted that she occasionally worries too much about things such as; grades, parents and self-image. The patient’s mother explained that patient is easily irritable, but not violent. She ascribed her anxiety to the feeling that something bad may happen to her or her loved ones. The patient denied any traumatic event that could possibly be a factor to her anxiety. She admitted to sometimes worrying about events that happened in the