Description

A.C. is a 17-y.o. female who presents with complaints of increased fatigue/ tiredness x 2 months. She endorses feelings of frustration, irritability, and mood lability; associated anhedonia, poor school performance, and unintentional weight gain (approx. 25-30 lbs.)

States symptoms were initially triggered by a breakup with her boyfriend but have increased recently. Endorses frequent episodes of crying and hopelessness. She demonstrates poor eye contact and is noted to be tearful during the visit. Exam reveals an obese young woman with abdominal striae, acanthosis nigricans, and mild acne on forehead. She denies suicidal and homicidal ideations and denies thoughts of self-harm. Social history notable for marijuana and alcohol use. She had been sexually active with her boyfriend but denied having multiple partners or recent activity.