Health History and Screening of an Adolescent or Young Adult Client

Health History and Screening of an Adolescent or Young Adult Client

Introduction

Background and Biographical Information

The patient is 18 years old, white female, single, and a student of high school. Some days ago she had an episode of high intensity occipital headache, after disagreement at school, which resulted in vomiting and photophobia, which improved after use of diclofenac. The next day she woke up not recognizing family or boyfriend, disoriented in time and space and not knowing identify objects, only remembering old facts, especially unpleasant.

Family History

The family has history of different health issues including hypertension and diabetes mellitus (DM) (paternal grandfather), asthma (brother), migraine (parents, maternal grandmother).

Social History

According to the data collected to the patient's social interactions, it has been revealed that she denies smoking, alcohol or illicit drug use, lives masonry house with sewer and water, two bedrooms, living with five people (uncle, aunt, cousin and brother) for ten months, parents separated two years ago, and lived six months with her mother and eight months with his father.

Discussion

Review of Systems

The patient has been suffering from occipital headache for two years, in distress, predominantly evening, casual, moderate intensity, exacerbated by stress or physical exertion without photophobia or nausea, improving with non-steroidal anti-inflammatory drugs (NSAIDs), as well as fatigue and insomnia.

Complementary Tests: CBC normal, normal biochemistry, normal urinalysis, EPF normal, normal chest radiograph, CT scan of the skull with normal reports.

Evolution

The patient has got her memory back after six days of first consultation. The case was diagnosed with anterograde amnesia, with the most likely etiology of the posttraumatic stress disorder (PTSD) type delayed because began six months after the trauma (Schwartz, 2003). The diagnostic conclusion came after reports of sexual abuse by her stepfather, and, before the symptoms listed in evolution, since the amnesia was short, there were no changes in the physical examination and laboratory tests demonstrating a psychosocial component.

Analysis

Memory loss or amnesia is the inability to store, retain, and recall coordinate knowledge, experience, information and skills acquired during recent and past life. It can be classified as anterograde amnesia, retrograde amnesia and transient global amnesia. The anterograde is the inability to store newly acquired knowledge, the retrograde recall experiences that occurred before the onset of amnesia, and transient global, to retain new information and old, but occurring in individuals over the age of 50, leaving them suddenly disoriented.

The main causes of amnesia in adolescence are infectious, like HIV, herpes simplex, syphilis, cryptococcosis, tuberculosis and sarcoidosis, metabolic, and vitamin deficiencies (B1, B3, B12), hypothyroidism and exogenous intoxication (drugs, illegal drugs and heavy metals ); neoplastic as primary tumor and paraneoplastic limbic encephalitis, neurological, and chronic subdural hematoma, post-anoxia, post-encephalitis and hydrocephalus; psychiatric disorders such as depression, schizophrenia and conversion reaction; degenerative diseases such as hereditary ataxias and motor neuron disease , in addition to others, such as vasculitis, acute intermittent porphyria, non-epileptic seizures and leukodystrophies. PTSD is a frequent disorder in children and adolescents, occurring after ...