You are seeing Haley Schilling, a 15 year old female, who’s coming to your office today at the behest of her mother. She has recently become more tired and her mom is concerned that she has ‘low blood.’ Take a focused history from Haley.
History
- Determines chief complaint is fatigue
- Inquires about onset and duration of fatigue
- Asks patient what she believes is causing her fatigue
- Inquires about patient’s mood (“I often feel low”)
- Inquires about association with other systemic symptoms – fever, chills, nausea (none)
- Symptoms suggestive of thyroid disease (cold intolerance, skin/hair changes)
- Excessive sleep (yes)
- Increasing weight, increasing appetite (yes)
- Feelings of worthlessness/guilt/isolation
- Pre-occupation with self image
- Poor concentration
- Psychomotor activation or retardation (activation)
- Suicidal ideation
- Suicide attempts
- History of self-harm behavior
- Symptoms of mania
- Symptoms of anxiety
- Symptoms of psychosis
- Establishes social context of child’s home-life and relationship with family
- Inquires about how the patient is adapting in school
- Relationship/sexual history
- Activities outside of school
- Past medical history
- Past history of depression and other psychiatric illnesses
- Current medications
- Alcohol, smoking, and drug history
- Legal history
- Current social supports
- Family history of psychiatric illnesses
Case 3 – Tired Teenager