Example Of A Medical Case Discussion

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1. DEMOGRAPHIC INFORMATION
Mrs. C is a 56-year-old, married, white female who lives with her husband and 18-year-old son. She has been married for 10 years. Mrs. C has her Master’s Degree in Special Education and works at the local Health Department.

2. INITIAL/GENERAL IMPRESSIONS
Mrs. C appears to be well educated. She is dressed professionally in black pants and blouse. She has good hygiene and well put together. Mrs. C was cooperative, open and willing to share her feelings. Mrs. C had a great attitude during the intake. Eye-contact was fine; hand coordination was fine, no impulsive words or movements.

3. REASON FOR COMING/PRESENTING CONCERNS
Mrs. C has experienced a lot of hurt and trauma in her life. At a very young age Mrs. C said she experienced physical and mental abuse. Her entire life she has had “people who loved her” leave her. Mrs. C reports she has depression that is interfering with her daily activities of life. Mrs. C said that the depression has worsened over the years and she is ready to get the help that she needs. …show more content…
BIRTH AND DEVELOPMENTAL HISTORY
Mrs. C reports her mother was 21 years old and her father was 24 years old when she was born. Mrs. C was born at 37 weeks and reports being healthy weighing 5 pounds, but does not remember her height and the labor was difficult due to doctors giving her too much medication that made her drowsy and was not able to wake up for 24 hours. Mrs. C says that her parents were married, but this was an unplanned pregnancy. Mrs. C says her mother smoked cigarettes, but did not drink or use any drugs. Mrs. C reports that she had no birth characteristics or developmental

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