Adolescent Depression

Laura Steadman; Karen M. Coles; Lisa W. Myers

Disclosures

Pediatr Nurs. 2018;44(6):308-310. 

In This Article

Case Presentation

Justin is an 18-year-old African-American male presenting to the clinic per his mother's persuasion. His mother reports that he has had fatigue, loss of energy, irritability, lack of motivation, decreased ability to concentrate, poor hygiene, low self-esteem, and weight loss. Justin refuses to interact with friends. His mother states: "He goes to school and then comes home and goes to bed or lays on the couch." His mother says she has noticed a gradual decline in his hygiene and lack of motivation over the last six months. She also reports that his grades have dropped from A's and B's to B's and C's this quarter. His mother denies Justin having learning problems.

Past Medical History

Currently, Justin does not have a primary care provider. Justin denies any food, environmental, or drug allergies. He admits to smoking a half pack of cigarettes on weekends for the last year and marijuana on occasion or when "I can find someone selling pot." Justin also admits to drinking beer when at social activities. His mother states he is up to date on immunizations. Justin denies constipation, diarrhea, dry skin, or heart palpitations.

Development and Growth History

Justin exhibits normal growth and development (weight and height) for age and sex.

Family and Social History

Justin's family medical history consists of diabetes, cancer, depression, and hypertension. Both of Justin's grandfathers have a history of hypertension and diabetes. Justin's father's paternal uncle has a history of depression. Justin's grandmother has had breast cancer. Justin's parents have been married for 20 years. He has two younger sisters who live in the home. In the past, Justin was involved in soccer and football; however, he does not express any interest in sports now. Justin states he had a "break up" with his girlfriend six months ago.

Nutritional History

Justin's appetite has decreased over the last six months, and he has experienced a 10-pound weight loss.

Physical Assessment Findings

General appearance: Justin comes to the clinic today at the urging of his mother due to her concerns for his mental health. He is awake, alert, and oriented to person, place, and time. He is cooperative and appropriately responsive to questions.

Vital signs: Temp: 98.6, Height: 69.5 in, Weight: 57.1 kg (126 lbs), HR: 72, RR: 16, BP: 128/82. BMI: 18.3.

HEENT: Normocephalic, conjunctiva clear, sclera clear bilaterally, EOMI, PERRLA, TM pearly gray with normal cone of light, no TM inflammation, no sinuses tenderness to palpation frontal, maxillary sinuses rhinitis, uvula midline, neck supple, no anterior cervical submental and submandibular tenderness or lymphadenopathy, thyroid not palpable, trachea midline, and full range of motion of neck.

Integumentary: Skin warm and dry to touch without lesions and/or cuts. Multiple red papules, open and closed comedones present to face. No bruises, rashes, or scars; erythema; discoloration; ecchymosis; or skin lesions noted.

Respiratory: Normal shape of chest with no obvious deformities. Respirations even and non-labored. Breath sounds clear bilaterally upon auscultation. No stridor, wheezes, crackles, or rubs. Good air movement.

Cardiovascular: RRR (regular, rate, and rhythm), without murmurs, rubs, or gallop, positive cap refill, 2+ pulses in all extremities noted.

Abdomen: Abdomen is soft, nontender, and nondistended; no hernias, masses or lesions noted. Active bowel sounds in all four quadrants. No hepatosplenomegaly.

Neurological/psychiatric: Oriented to person, place, and time. Makes appropriate eye contact and conversation. Speech and cranial nerves 1-X11 normal. Mood and affect are confluent and full range. Thought process is linear and goal-directed. Denies suicidal/homicidal ideation, auditory and/or visual hallucinations. Insight and judgment are good. Has poor grooming and hygiene. Is cooperative. Speech is spontaneous and normal.

Musculoskeletal: Full range of motion (ROM). 5/5 strength UE/LE bilaterally. No edema noted, ambulates with a steady gait, good ROM in all major joints, 5/5 strength against resistance. Normal, equal strong dorsi/plantar flexion.

Genitalia: Tanner Stage V noted. Extensive assessment not completed at this visit. Denies dysuria and/or urgency.

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