MENTAL STATUS EXAM:

CASE OF AERA

 

Intake Date: February 2021

 

IDENTIFYING/DEMOGRAPHIC DATA:

Aera is a 27-year-old, single Korean female. She has never been married. Aera has a 9-year-old son from a prior relationship. Aera did not graduate from high school but returned to school to get her G.E.D. She is presently a first year student at a community college. She is working in the college library in conjunction with a work-study program. Aera’s goal is to become a teacher. Aera identifies herself as lesbian which does create some conflict with her family.

 

CHIEF COMPLAINT/PRESENTING PROBLEM:

“I find it hard to concentrate, and have difficulty sleeping. I wonder if I’m going crazy.”

 

HISTORY OF PRESENT ILLNESS:

The intake was precipitated by Aera’s inability to concentrate and stay focused. Aera reports she has felt like this since she was a teenager. She also states that one year ago, she began to develop what she described as a panic attack. She is always worried about something and her heart beats very fast and she has sweaty palms, often throughout the day. She reports that she does not want to go to class because she fears that “I’ll say something stupid.” She often has to re-read class material several times before she can absorb it and often thinks about leaving school. Aera thinks that these symptoms may be due to her son’s placement in special education classes. Aera reports that she does not go out as much anymore because she likes to stay home with her son. Aera reports she sleeps for a few hours every night, with difficulty falling asleep and waking up in the middle of the night with an inability to fall back a sleep. She reports no change in appetite.

 

SUBSTANCE USE HISTORY:

She denies all substance abuse. She reports she will have only one drink on a special occasion or if she goes out, which is rare. Aera tried marijuana once when she was a teenager, but states she never tried it again because “I didn’t like the way it made me feel.”

PAST PSYCHIATRIC HISTORY:

Aera denies any past psychiatric history. She reports this is the first time she has ever seen a therapist. Aera states she has always worried due to her family issues when growing up. The worry has become so normal she no longer tries to stop it.

 

PAST MEDICAL HISTORY:

Aera denies any significant medical history. She states she has had normal childhood illnesses. There is no significant weight gain or loss.

 

FAMILY MEDICAL AND PSYCHIATRIC HISTORY:

Aera states her parents never married. Her parents’ relationship was on again/off again, but her dad left for good when Aera was 14-years-old. Aera was pleased when her father left for good, stating he was a “bad man.” He drank a lot. Her parents fought frequently, and her father would physically abuse her mother. Aera believes her mother deserved the beatings because she cheated on the father.

 

CURRENT FAMILY ISSUES AND DYNAMICS:

Aera is the first of 3 daughters from her parents’ union. She is aware of two half-sisters on the paternal side. Aera is unsure if her father has more children. Her mother had another daughter 10 years ago. Aera reports her mother kicked her out at 16-years-old because Aera interfered with her mother’s relationship at the time. Aera lived with friends in her later teens. She returned home at 19-years-old when she found out she was pregnant. The child was the result of her first sexual experience. She never continued a relationship with the child’s father, although he sees his son periodically.

 

Aera has no close friendships. She has a female friend that she cannot bring around her family. She has had one other relationship for 9 months a few years ago. More recently Aera likes to stay home with her son in her leisure time. She liked to go out to the movies in the past but that has changed. She finds she has no energy to go out any longer and always feels tired.

 

MENTAL STATUS EXAM:

Aera presents as a casually dressed female who appears her stated age of 27. She is tense during the interview and her affect is blunted. Motor activity is appropriate. Speech is clear. At times during the interview, she lost her train of thought and had to be redirected to the subject. There is no evidence of delusions or hallucinations. Aera’s intelligence appears above average. She is oriented to time, place, and person. Aera denies suicidal and homicidal ideation in the past or present.


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