Miss S.A. is an 18-year-old Hispanic female, who presents to the on-campus student health clinic for a winter screening. Miss S.A. reports concerns of extreme fatigue, sleep disturbances (causing difficulty attending classes), and describes not feeling like her usual self; “my roommate recently asks why I’m getting so ticked off about the dumbest things”. The client reports frequent, unexpected crying spells for an unknown reason, only that she feels empty and hopeless inside. Miss S.A. reports she has been feeling this way for about the past 2-3 weeks.
Past Medical History:
- No history of serious illness, hospitalizations or surgeries reported
- No current prescribed or OTC medications
- No history of substance use/misuse
- Positive suicidal ideation without intent/plan; last occurrence approximately 1 week ago
- Reports a decreased appetite secondary to upset stomach
- Recent unintentional weight loss of 10 pounds over 3-4 weeks
- Recent routine physical with routine labs including normal thyroid panel
Pertinent Family History:
- Parents divorced when the patient was 7 years-old
- Limited known family history, suspect of maternal depression
- Paternal grandfather deceased secondary to suicide in 2012
- No known family history of thyroid disease, chronic or serious illness
Pertinent Social History:
- Full-time college student (Freshman year)
- First time living away from home
- Reports recent decreased interest in engaging in social/extracurricular campus activities
- Reports, “I’ve been keeping to myself lately”
- Small to minimal support system reported