Week 5 Case Study: JAEDYN

Week 5 Case Study

Week 5 Case Study: JAEDYN

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CASE OF JAEDYN   

Intake Date: October xxxx 

IDENTIFYING/DEMOGRAPHIC DATA: Jaedyn is a 19-year-old Caucasian female who resides in California with her parents and 2 siblings.  Jaedyn comes from an upper-middle-class family.  She attended private high school and is now attending college in Southern California.   

CHIEF COMPLAINT/PRESENTING PROBLEM:  Jaedyn stated she is “ugly”, and others are laughing at her.  She describes that this has been happening since she was 13 years old.  Now the pain of her “ugliness” is affecting her friendships and her ability to enjoy the end of her teenage years.   

HISTORY OF PRESENT ILLNESS:  Jaedyn noticed from her early teens that her nose looked fat and her eyes seemed far apart.  She begged her parents to let her get surgery on her face, but they refused, indicating that she was too young for that at the time.  Now that Jaedyn is 19, her parents are considering the surgery, but they want to confirm that it is something she really wants.  Jaedyn has always been a good student and socially active.  When she was younger, she was more confident but as her teenage years progressed, she became less confident.  This was due to her feelings of being ugly and thinking others are noticing her in a negative manner.    

Jaedyn is finding herself staying away from college activities.  Her grades have started to decline since she no longer can concentrate on schoolwork.  She finds herself thinking about her defects all the time.  She sits in her room and does not attempt to do any activity. 

PAST PSYCHIATRIC HISTORY:  Jaedyn began to pick at blemishes and hairs on her face.  She believes they just stand out and that is what people are looking at. 

SUBSTANCE USE HISTORY:  Jaedyn reports drinking a bit in high school.  She denies any illicit drug use.  She reports not drinking in college since she will not go to the parties because of her looks. 

PAST MEDICAL HISTORY:  Jaedyn has been to several plastic surgeons and medical doctors worried about the blemishes on her face, her nose, and eyes.   

CURRENT FAMILY ISSUES AND DYNAMICS:  Jaedyn’s sisters are always making fun of Jaedyn because she frequently checks herself in the mirror and other reflective surfaces.  The family is constantly reassuring Jaedyn that her looks are fine to no avail.   

MENTAL STATUS EXAM:  Jaedyn looks her stated age of 19.  She is well dressed, with long blonde hair and presents very well physically.  Jaedyn describes her mood as depressed.  Her eating habits and weight is unchanged from earlier years.  Jaedyn does report passive suicide ideation, just thinking she wants to die since the stress of her looks has become overwhelming

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