Introduction:
The patient is a 14-year-old African American female to male transgender individual. The patient uses the name Joseph and masculine pronouns (He, him. His). He is evaluated in a child and adolescent inpatient crisis unit.
Chief complaint:
“My parents don’t understand me”.
History of chief complaint:
Patient came out as transgender on social media two years ago. At the time, he asked his parents and friends to call him Joseph. And to refer to him using masculine pronouns,( he, him, his). He wants to wear only boys clothing, use the boy’s bathroom at school, and participate in groups and activities for boys. Patient reports that his parents are not accepting of his transgender identity and that their lack of acceptance has contributed to increased anxiety, Depression and suicidal ideation. The patient told his outpatient therapist that he was planning to kill himself by running into oncoming traffic. Therapist contacted his parents who brought him to the hospital for evaluation. The patient reports engaging in self-injurious behavior by making superficial cuts on his forearms and occasionally on his breast. “Because I hate them, I don’t want them”, Patient reports. His last episode of self injury was two nights ago when he used a razor to cut his left. 4. He reports I can’t seem to focus and that he is in danger of failing 2 of his classes. He has been sleeping most afternoons after returning home from school. Patient reports feeling very sad for the past month. He states he has been eating more than usual and has gained 10 lbs in the past month. He is currently prescribed fluoxetine 40 milligrams by his outpatient psychiatrist.
Past psychiatric history:
patient has been in outpatient therapy on and off since age 4 because of anxiety and issues with gender identity. He had several trials of medications for attention deficit hyperactivity disorder ADHD) as a young child. He is currently taking fluoxetine 40 milligrams with some effects on anxiety and depression. They had in home family therapy for six months following a referral from the patients school. The therapy ended four months ago. This is his first psychiatric hospitalization.
Medical history:
Exercise induced asthma. Several superficial healing cuts observed on patients left forearm.
History of drug or alcohol abuse:
Patient reports smoking about 5 cigarettes per day. He denies use of alcohol, marijuana or other illicit substances. He denies use of any unprescribed hormones.
Family history:
Limited information available about patients biological family, but substance abuse problems (specific substance unknown) were suspected in patients biological mother. The patient’s adoptive mother has a history of depression.
Personal history:
Perinatal: Unknown because the patient is adapted.
Childhood: The patient was adopted at age 5 after having been in foster care since age 3 because of neglect and physical abuse by his biological mother. No other children live in the home. The patient began to express cross gender identity at age 12. He insisted on wearing boy’s clothing and used the boy’s bathroom at school even though they did not permit this.
Adolescents: The patient expresses distress at developing secondary sex characteristics associated with females. He is currently binding his breast to create the shape of a flatter chest, he reports. Intense dysphoria around the time of menstruation. He is attracted to girls and identifies as heterosexual.
Trauma and abuse history:
Physical abuse and neglect by the biological mother from birth to age 3.
Mental status exams:
Appearance; Shot hair, dressed in masculine clothing, wearing eyeglasses.
Behaviour and Psychomotor activity: Restless bouncing right leg throughout assessment.
Consciousness; Alert.
Orientation; Oriented to person, place and time.
Memory: Not formally assessed, but appears to be intact during this assessment.
Concentration and Attention: Reports impaired concentration and appears mildly distractible during assessment.
Visual Sceptileability; Not assessed.
Abstract thoughts; Not assessed.
Intellectual functioning; Average.
Speech and language; Rapid, mildly pressured.
Perceptions; No evidence of perceptual disturbance.
Thought processes; Coherent gold directed.
Thought content; No abnormalities.
Suicidality or homicidality; Suicidal ideation with plan to run into traffic. Uncertain intent.
Mood; Down.
Affect; Concurrent with mood, constricted.
Impulse control; Good during the assessment. His history of self-injurious behavior may be an indication of impulsivity.
Judgement/ inside /reliability; Fair/ moderate /moderate.
Essential elements.
- List any additional questions or information you would want to know.
- Differential diagnosis should include rationales. Do not forget medical diagnosis.
- Where can diagnosis primarily, secondary, and medical if indicated?
- Your treatment plan should include medication, therapies, health promotion, tools.
- How has the assigned article contributed? To your knowledge about the case.
Simulated Case Scenario and Discussion/Treatment Plan
For this assignment you will need to read the article and review the scenario, answer the
questions posed thoroughly found in the objective section of case presentation, utilize evidence-
based article to support your diagnosis and or treatment for this client. Students should prepare
a comprehensive treatment plan for this client as if they were going to be following the
progress. This should include referrals, medication, labs, etc. This should be written in a
narrative format.
