DSM-5 Case Review

CASE OF GABRIELLA

INTAKE DATE: May 2020

DEMOGRAPHIC DATA: This is a voluntary admission for this 20 year old Hispanic female. This is Gabriella’s first psychiatric hospitalization. Gabriella lives at home with her parents. Gabriella is a college student in her second year.

CHIEF COMPLAINT: Gabriella was brought to the emergency room by some friends in a state of anxiety and agitation. She had been out for the evening with some friends at a party and after about half an hour, Gabriella appeared tense and anxious and complained that everything was changing. She could see the faces of her friends increasing to about three times their natural size. The room became distorted, and its proportions and colors kept altering. She felt that the party goers were talking about her in a menacing way, so she suddenly rushed outside because she felt that she was in danger. HISTORY OF ILLNESS: There is no indicated history of current illness. See Chief Complaint, Medical history, and Substance Use History. PAST PSYCHIATRIC HISTORY: Gabriella denies any past psychiatric history. MEDICAL HISTORY: A physical examination revealed bloodshot eyes and an increased pulse rate of 120 beats per minute, her heart was beating so fast. A neurological examination also revealed no abnormalities. Gabriella had heightened sensitivities to external stimuli, reporting colors seem brighter and richer, and a subjectively slow appreciation of time. Motor skills were impaired so it was helpful that her friends would not let her drive. Gabriella denied any major illnesses. SUBSTANCE USE HISTORY: Gabrielle states she is a social drinker. She admitted to having two beers at the party. She then decided to use marijuana. She had smoked marijuana on a previous occasion but this time she ate a lump of cannabis despite warnings from her friends. She became increasingly agitated and started running down the middle of the street, dodging in and out among the traffic. Eventually, her friends were able to catch her. They were unable to quiet her anxiety and had a hard time persuading her to go with them to the hospital.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Father and grandfather have a history of cardiovascular disease. PSYCHOSOCIAL AND DEVELOPMENTAL HISTORY: Unable to obtain. MENTAL STATUS: Gabriella presents as a casually dressed female who appears her stated age of 20. Posture is relaxed. Facial expressions are appropriate to thought content. On examination Gabrielle appeared tense and apprehensive, looking around the room as if she felt uneasy with the surroundings, but she denied perceptual symptoms and did not really believe that she was the subject of persecution. She was fully aware of her surroundings, but her attention was fleeting, and she did not always answer questions. There was no marked impairment of memory, and she was fully oriented. Speech is fuzzy, there are no speech impediments noted. Thoughts were sometimes illogical and disorganized. There is no evidence of delusions or hallucinations. Gabriella denies suicidal or homicidal ideation. In the course of a few hours, Gabrielle quieted down. When she felt better she left the hospital with her friends.