SOCW6090
CASE PRESENTATION – ANNIE
Intake Date: July 2020
IDENTIFYING/DEMOGRAPHIC DATA: Annie is a white female, 29 year old who lives in Oregon with her husband Dwayne and four sons. She has been married 12 years. She is a homemaker and does not work outside the home. Annie and Dwayne own several mini golf locations throughout Oregon.
HISTORY OF PRESENT ILLNESS: Annie experienced a seemingly traumatic event while at a community function at the beach. From the incident she seems to have forgotten who she is. After a complete medical workup there is no evidence of organic brain dysfunction. The situation has caused Annie a lot of emotional distress.
PAST PSYCHIATRIC HISTORY: Annie has never had a history of psychiatric treatment.
SUBSTANCE USE HISTORY: Annie drinks socially. She denies any drug use. Her husband Dwayne concurs that Annie is not a big drinker and drinks on occasion. He has never seen Annie intoxicated.
PAST MEDICAL HISTORY: Annie has yearly physicals. There has never been any concern with medical issues. Annie at times has painful menstrual periods but not on a monthly basis.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Annie comes from a more affluent family. She met Dwayne in high school when the football teams were competing each other. She has been with Dwayne ever since. Her parents did not approve of Dwayne since he was Black. Annie has very little contact with her family even though her marriage to Dwayne has proven to be very successful.
CURRENT FAMILY ISSUES AND DYNAMICS: Annie continues her role as wife and mother but is having difficulty adjusting to it. She is very distressed that she cannot remember her past. The doctors have told Annie that her memory probably will come back suddenly. Annie stays isolated now since she cannot remember her past with all her social activities and friends. Annie was very involved with her children’s school and church activities.
MENTAL STATUS EXAM: Annie is not oriented to time, place, or person from the past. She is oriented to what she has been told since the incident on the beach. She could do serial 7's and all memory tests. Short term memory, since the incident is adequate but long-term memory is lost. Concentration is not impaired. Patient denies homicide and suicide ideation. Her affect is flat and mood dysphoric. Annie indicates her sleep is impacted, sometimes waking up and worrying. When asked how she sees herself in five years, she said "hopefully with my memory back, only healthier."