NU 664C: Family Psychiatric
Mental Health I
Week 10 Assignment 1: Alexandra
Katsaros iHuman Case Study
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Week 10 Assignment 1: Alexandra Katsaros
... [Show More] iHuman Case Study
Informed Consent
Informed consent is given to the client about the psychiatric interview process and
psychiatric/psychotherapy treatment—verbal and written consent to treat signed by the client.
Identifying Data
Name: Alexandra Katsaros Age: 22 years old Race: Caucasian Gender: Female
Chief Complaint (CC)
“I was feeling overwhelmed.”
History of Present Illness (HPI)
Alexandra Katsaros is a 22-year-old cisgender female who presents to the emergency department
due to an unarousable episode. The client reports that she does not “remember exactly what
happened” but states that she was out with friends the previous night, drinking “maybe two beers
and three hard drinks” and smoking marijuana. The client reports going home afterward and
having an argument with her ex-boyfriend, whom she lives with. The client states she remembers
being “really irritated and angry” after her ex-boyfriend revealed that he went out with one of her
“good friends.” The client reports feeling overwhelmed by the argument as she already had a
headache and ingested four acetaminophens with diphenhydramine with the intent to go to sleep.
The client stated that “it didn’t work” and proceeded to take two 1 mg tablets of alprazolam. Per
the client’s ex-boyfriend, the client could not wake up from the couch; he got distraught and
brought her to the ER for evaluation. The client denies any SI, HI, AH, and VH. She denies any
current or past suicidal ideation, suicide attempts, or self-harm behaviors. She reports feelings of
worry started three weeks ago after her breakup and needing to find a new place to live, and “not
having to see my ex-boyfriend all the time.” She reports the breakup as a significant stressor
contributing to increased anxiety symptoms, difficulty falling asleep but not staying asleep (9
hours of sleep per night), frequent headaches, muscle tension, and difficulty focusing at work and
school. She reports that her anxiety feels better when she is with her sisters and states that getting
away from her ex-boyfriend would make her feel “a little better.”
Past Medical History (PMH)
Allergies: Penicillin; client reports hives as an allergic reaction
Current Medications: Synthroid 75mcg PO 1 tab daily, oral birth control pill, Tylenol OTC
PRN, alprazolam 1mg tab PO PRN for insomnia (prescribed by PCP a year ago).
Childhood Illnesses: Denies any significant childhood illnesses.
Adult Illnesses: Hypothyroidism (diagnosed three years ago). Ongoing thyroid-replacement
therapy.
Psychiatric: Previous diagnosis of depression in high school after a breakup, but denies any
psychopharmacologic or psychotherapy treatment. Possible undiagnosed ADHD was reported
based on the teacher’s observation. Denies any prior inpatient psychiatric hospitalization.
Obstetric/gynecologic: G0P0
Immunization Status: Up to date.
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Family History
Mother, alive, diagnosed with depression and anxiety. The client reports that mom takes Xanax
and Paxil. Father, alive, alcohol abuse disorder. Siblings, alive, two sisters and one brother, no
pertinent history reported.
Personal and Social History
The client currently lives in Illinois with her ex-boyfriends and is looking for a new place to live
following her recent breakup. She is a student at a community college taking health science
classes. She works at an art gallery five hours per week as a moderator. She reports growing up
in a strict religious Catholic household with both parents and three siblings: 2 sisters and one
brother. She reports having a close relationship with her sisters who live in town. She also reports
having two close girlfriends who have been supportive since her breakup. She reports drinking
two to three beers once or twice during the week and on the weekends. She reports drinking wine
or hard liquor, but rarely both when she goes out with friends. She reports smoking marijuana a
couple of times yearly with friends. Denies tobacco use or any other recreational drugs.
Review of Systems
Negative ROS except client reports frequent headaches relieved by OTC Tylenol and change in
appetite since the romantic relationship break-up. No significant weight loss was reported.
Objective
Weight: 122 lbs (55.5kg); BMI 20.3
Height: 5’5” (165cm)
Vital Signs:
Temp: 98.2 F (oral) BP: 100/66 mmHg left arm, sitting position HR: 60 bpm
RR: 18 bpm; regular and unlabored SpO2: 99% room air Pain: O on a 0-10 scale
General appearance: Anxious and occasional tearful. Fair eye contact. Faint odor of alcohol.
Skin: Warm, dry
Mouth: Charcoal stained mouth due to gastric lavage
HEENT: Normocephalic, atraumatic, PERRLA
Neck: Thyroid WNL for size and consistency. No nodules.
Chest/Lung: LSC to auscultation bilaterally. No rales, rhonchi, or wheezing were noted.
Abdomen: Flat, symmetric, non-distended.
Cardiovascular: Normal S1 and S2, no S3. No rubs, murmurs, or gallops.
Neurologic: A+O x4. CN I-XII grossly intact, slight psychomotor retardation
Laboratory and Diagnostic Studies
Blood Alcohol concentration: (164mg/dL) Normal
Acetaminophen (paracentamol) level, blood: (11 Ug/mL) Normal
Complete blood count (CBC) with different: Normal
Comprehensive metabolic panel (CMP): Abnormal levels; hyperchloremia 104mmol/L (ref.
range (95-102mmol/L); hypokalemia 3.3mmol/L (ref. range 3.5-5.1mmol/L)
Thyroid Function tests (TFT): Normal TSH and FT4
Drug toxicology testing, urine: Positive for benzodiazepine use
Human Chorionic gonadotropin (hCG), urine: Negative [Show Less]