SOCW 6090

CASE PRESENTATION – SANTIAGO

 

Intake Date: July 2020

 

IDENTIFYING/DEMOGRAPHIC DATA: Santiago is an 11-year-old Hispanic male who lives with his grandmother and mother Sofia in Nogales, Arizona. Santiago’s father has not been in his life over the past two years.

      

CHIEF COMPLAINT/PRESENTING PROBLEM: Two years ago Santiago stopped talking and lost his hearing and sight. The medical doctors cannot find any physical reasons for his challenges. After many visits to doctors they decided to bring Santiago to a clinical social worker.

 

HISTORY OF PRESENT ILLNESS: Santiago and his family live in a gang ridden area in Nogales. Sofia’s husband Juan was protecting Sofia from being attacked by a gang leader and Santiago watched his father shoot the gang leader as he was attempting to attack Sofia. When Sofia and Juan realized that Santiago saw this, they feared for his life and worried he may say something about this murder. Sofia violently shook Santiago telling him he did not see or hear anything. Two months later Santiago lost his sense of hearing, seeing, and speaking.

PAST PSYCHIATRIC HISTORY: This is the first psychiatric visit for Santiago.

SUBSTANCE USE HISTORY: There is no reported substance use for Santiago.

PAST MEDICAL HISTORY: Santiago had wellness checks from the time he was born. There were no medical issues other the normal childhood illnesses.

 

FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: No reported medical or psychiatric family issues.

 

CURRENT FAMILY ISSUES AND DYNAMICS: Santiago was a good student up to 9 years old. His parents helped Santiago stay focused on his studies, wanting more for him outside the neighborhood. Since Sofia’s mother was elderly and ailing they were not prepared to leave the area yet but had future plans of doing that. Santiago has never been in trouble at school or at home. His parents have kept him isolated, with few friends, due to their worry about Santiago getting involved with gang activity.

After the death of the gang leader Juan decided to leave the area to protect his family. At this point, it is unknown if Juan is alive or not.

Santiago does not engage with others, including his mother and grandmother. He only responds to a man on the street who plays the guitar in the street for money. Sofia and Santiago encounter this man when they go to the bodega. Santiago likes to just sit there, but they typically do not stay long since Sofia fears the neighborhood.

Santiago is no longer in school.

MENTAL STATUS EXAM: The social worker was unable to do a full mental status exam with Santiago since he was mostly catatonic.