Chief Complaint
“I don’t want to live. I just can’t take it anymore.”
History of present illness
Ashley is a 14 year old white female, who was brought to the emergency room by her step-father after mentioning that she was having suicidal ideation. Ashley has a pertinent medical history of cutting that began at the age of 12. She reports that she has begun “feeling down” since the beginning of her freshman year in high school, which was approximately 3 months ago. She states that she “feels down” every day. “I just feel worthless.” She reports that she began having intermittent feelings of self harm approximately 2-3 weeks ago. Ashley does not currently have a plan on how she would follow through with harming herself. She denies homicidal ideation. She denies having a history of depression. She states that she hasn’t been able to concentrate as well lately. She also reports that she isn’t sleeping much at night and has lost 15 pounds in two months. “I have a hard time at volleyball practice and with my school work because I don’t have any energy at all.” Ashley reports that she feels safe at home in her environment. Her biological mother is not present as she is at home with a younger sibling.
Past medical history
- Cutting, began at age 12
- Left knee anterior cruciate ligament tear, October 2013
- Recurrent otitis media as a toddler
- Chronic strep throat
- Current on routine immunizations
- Gardasil x 2, last injection was September 2015. Last of the series is due February 2016
Past surgical history
- Wisdom teeth extraction, June 2014
- Bilateral eustachian tubes, March 2000
- Tonsillectomy and adenoids, November 2002
- Bilateral eustachian tubes removed, February 2003
- Left knee anterior cruciate ligament repair, July 2014
Pertinent family history
- Biological mother is 40 years old, alive and healthy
- Biological father is 42 years old, alive but has not been in contact with Ashley for the last 10 years
- Half sister age 5, alive and healthy
- No known family history of depression
Pertinent social history
- Full time high school student
- Participates on the freshman volleyball team
- No illicit drug use
- No etoh use
Allergies
- Amoxicillin (skin rash as a child)
- Bicillin L-A (skin rash as a child)
- Norco (nausea and vomiting)
- Phenergan (hives)
Medications
- Tylenol and/or ibuprofen prn
Focused physical exam
- Lungs are clear to auscultation bilaterally
- Well groomed, skin pink, warm and dry
- Respirations easy and non-labored
- Vital signs are within normal limits
- Teary eyed
- Avoids eye contact
- Verbalizes anger that her step-father “made me come here”
- Healed scars noted to bilateral wrists (horizontal in nature)
- Recent superficial self-inflicted cuts to pt’s upper bilateral thighs
- Last menstrual period 1 one week ago
Photo credit: http://hecticparents.com/tag/depression/