Week 10 Assignment 1: Alexandra Katsaros iHuman Case Study
Informed Consent
Informed consent is given to the client about the psychiatric interview process and
psychiatric/psychotherapy treatment—verbal and written
...
Week 10 Assignment 1: Alexandra Katsaros 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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