Kelly is a 22 year old African American woman who is of average height though overweight (she reports she is 50 pounds over her desired weight). She arrived at the meeting on time and was neatly dressed and well groomed. She evidenced no abnormal movements but moved slowly. She was cooperative and pleasant throughout the meeting. Kelly maintained eye contact off and on. She did not maintain eye contact when discussing the loss of her mother in a drunk driving accident and the loss of a four year relationship. Kelly’s speech was organized though she spoke softly and hesitated in the middle of sentences. She willingly answered questions though when discussing difficult topics she dropped her head and it was difficult to hear her. Lucy articulated clearly and answered questions spontaneously, although at slow rate.
Kelly’s range of affect was restricted. She evidenced flattened affect which was in the depressed range. Kelly evidenced a poverty of thought evidence by the inability to generate more than one possibility to problem solving questions and she answered questions with one word answers when discussing her ex-boyfriend and mother. She did not evidence any formal thought disorder and was able to answer questions directly though with little content. Kelly expressed that she was depressed and a little anxious about her breakup, her mother’s death and her excess weight. She was concerned about her health and that the weight would prevent her from attracting men. She stated that she had tried to lose weight but had been unsuccessful which made her feel like “a loser”. No suicidal ideation past or present was endorsed. Kelly exhibited normal perceptual abilities and there were no delusional or psychotic symptoms detected.
Kelly was alert and orientated X 3 (person, place and time). Kelly clearly understood the health implications of being overweight but was unable to accept that food was a coping mechanism for her. She stated that in her family eating was used as a reward and for comfort, and she still gravitated toward food when she felt bad. She was also able to determine that if she found an envelope with a stamp on it she would mail it showing problem solving ability.
Kelly was able to explain recent news events in a limited manner. She could not remember a number of newsworthy events from the past. She was able to recall 3 words (orange, alligator, Lexus), immediately and after five minutes. On serial 7’s Kelly counted back from 100 to 50 missing the last 4 trials. She could recite the Alphabet backwards correctly until the letter “p” after which she became too frustrated to continue.
References
[I was unable to cite the ref as the client did not provide the one for the required readings]
