Depressive Disorder in adolescent population

Temperature: 98.6 F (oral)

Pulse: 70 bpm – regular

Blood pressure: 110/74 mmHg

Orthostatic blood pressure: 104/70 mmHg upon standing

Respiratory rate: 14 bpm

SpO2: 99% on room air

Chief complaint: Fatigue

Allergies: None

History of Present illness: Around 12:00 PM Patient arrived to the clinic reported that her mom made her come here because she is tired all the time. (Eyes are tearful, slightly annoyed tone of voice), but she is doing fine. The fatigue stated 2 months ago or so. With her eye tearful, she reported she doesn’t know what really triggers her fatigue, because it is her senior year, they lay on a lot of pressure, you know. Her mother believes her fatigue is physical, but at the same time she said her mother is worried about the following behaviors Her Angry, Irritable and snap at her little sister, but she doesn’t know what triggers her anger. She reported, if her mother stops bugging her, she would have not been so crappy, like her calling her behavior. She found her parents irritating and they are always in her case. She feels like she can’t do anything right, school is not fun anymore just doesn’t seem worth it most of the time, she gets upset so upset and frustrate and she is crying every day. A.C stated “If she just took the time to listen to me she would understand.” Nothing makes her fatigue better or worst. She just not interested in doing anything. She reports still feeling tired even she gets a good night of sleep. She doesn’t like the way she looks. She gains 25-30 Lbs. and concern about her straight mark. She is feeling anxious a bit. She is crying every day since she lost her boyfriend. Not feeling great about herself

She is feeling bored. Do not want to stay home, nor wants to stay home. Her mother thanks she screw up. She is avoiding society, ever since her boyfriend left her last year for another friend while she was at the prom and she has not dating anyone else yet. Not able to focus on school. Her grade is going down

She doesn’t care anymore like she used too. She is eating poor diet. She has to share room with her sister, who is a freshman. She cannot stand the way her sister is excited about high school and the mess she creates in the room, drive her insane. Her sister and her friend are so annoying and she is crying while she saying that. Her mother is her case about spending too much time in the internet rather than being social and her mother is also on her for helping around the house. Lost her baby sitting job. Drink beer at parties occasionally with friends

Feeling hungry all the time

Denies been pregnant

Past Medical History: She had Croup at age 2

Fracture of right wrist (rollerblading) at age 11 and she was in 5^th grade

Medication: Ibuprofen for menstrual cramps. They there for each period, but not that bad.

Social History: She is in Senior currently High School getting ready to graduate

She tried marijuana last year with her old boyfriend, nothing else through.

Drinking alcohol. Lost her baby sitting job. Sharing room with her little sister.

General Appearance:

Expression:

Hospitalization none

Childhood sickness: none

Medication: Ibuprofen

Preventive measures: Yearly physical check-up Learning to drive, but says she knows better than to text and drive. Gets regular dental and annual wellness evaluations

Immunization: Up-to-date

History of Family: Father: Mild HTN, obesity

Mother: Obesity

Brother is 10 years old

Sister

Maternal grandmother and aunt Positive FH for type 2 DM

Review of system Answered by patient

General/ Constitutional:

Mental status: Awake, Alert and oriented X4

Skin/Breast: Nomal

HEENT & Neck: No complain