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How can I Come out with a leading diagnosis and the rationale for that diagnosis Differential diagnosis about 3 The screening tool possible to use to guide diagnosis possible treatment education to give to the patient Any other relevant information Informant:Direct interview of the patient and her mother Chief Complaint: Anna Sing (AS) is a 16 year old Asian girl who presents with her mother saying that my mother thinks I am a “difficult child” and wants me in treatment. She says it is for “my own safety.” AS’s mother says she is concerned because the client focuses too much on her weight. HPI: AS was referred by her family practitioner following a sports physical. AS says her mother is overly concerned about her weight. She feels she is too fat. Her mother says that about a year ago AS became “very concerned about what she ate, and began reading labels and avoiding fat, by obsessively cutting off any apparent fat from foods eventually becoming a vegetarian.” Said her and her husband initially saw this as positive but AS continued to “obsess” on her weight. For the past several months she will only eat dry toast and drink diet Pepsi. Her mother says AS likes to cook but after preparing a meal for the family will not eat the food she has prepared and recently refused to eat with the family. Past Psychiatric Hx: None Medical Hx: AS is adopted so little is known about her biological mother’s health and prenatal course. She was born vaginally with no known complications to a Vietnam refugee who was immigrating to the U.S. Unable to obtain an abortion she put AS up for adoption. AS’s biological father was also Vietnamese. AS had childhood asthma which she seems to have outgrown. Her mother reports she was always concerned about her weight and was upset when she took predisone for acute asthma S&S and gained weight. Her mother became alarmed when she took AS for her yearly sports physical and found she had lost twenty pounds from the previous year. AS’s present Ht: is 62 1/2″ and Wt: 51Kg. She began menarche at age 15 and her menses have always been irregular. AS denied any drug use except for trying “pot” and OTC weight loss pills. Developmental Hx and Milestones: AS’s adoptive parents received her when she was 3 weeks old. Her mother describes her as a “good baby” although she had “colic” for the first 3 months for 1 to 2 hrs each day around 5 to 7 p.m. and was inconsolable during this time. Said once this period passed she was a relatively easy baby and was very “precocious.” The mother indicates AS met or exceeded childhood milestones and her favorite activities were “dressing up in play clothes and playing with her Barbie dolls.” Family and Marital Hx: AS’s adoptive parents are from upper middle class background, college educated. They met in college and married shortly after finishing. Initially, they delayed having children so they could get “established” but when they were unable to conceive and after several attempts at artificial insemination decided to apply for adoption. AS’s mother stopped teaching after the adoption because she wanted to devote her time to AS and because her husband, an accountant, traveled a lot and she knew it would be difficulty to raise children if they were both working. Family Psychiatric Hx: Little is known about AS’s biological parents. Her birth mother returned to Vietnam shortly after giving birth and whereabouts of father is unknown. Education and School Hx: AS was involved in gymnastic and violin. She attended a Montessori preschool before beginning primary grades at a parochial grade school. She did well in school and is now a sophomore at a private high school where she earns all most all As. Peer Relationships: AS says she has “lots of friends” but admits minimum interaction with all but a few friends and acknowledges some anger toward specific peers. Mother says she has been more isolated in the past year, “staying in her room much of the evening reading Vogue or Glamour when not doing her homework.” Current Family Functioning: AS lives with her parents and adopted brother from Korea who she says she gets along well with. She believes her mother is overprotective. Mental Status: AS is a thin, serious looking adolescent with long straight black hair worn in a ponytail. She was dressed in jeans and a sweatshirt and has three rings in her left ear. She spoke in a hesitating manner and appeared somewhat angry. Her posture was tense when interviewed with her mother and she would occasionally look annoyed at her mother when her mother discussed her weight and eating behavior. She was more relaxed when interviewed alone, sharing her desire to be “perfect” and her interest in what actresses wore to the Academy Awards. She admitted she felt anxious if she didn’t get her homework done at least three days before it was due and admitted she sometimes has difficulty falling asleep because she worries if she has completed all the things she needs to do. She reports not believing she is pretty and wishes she “had someone else’s body.”

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