Path Week 9nchel88
CASE of CHIN SUN
INTAKE DATE: January 6, 2021
IDENTIFYING/DEMOGRAPHIC DATA: Chin Sun is 22-year-old and the oldest child of two working-class parents. Chin Sun has one younger brother, aged 9. Both parents immigrated from Korea. Chin Sun lives in San Francisco with her parents. She is finishing up her final year at college.
CHIEF COMPLAINT/PRESENTING PROBLEM: “I am having trouble sleeping since I witnessed a stabbing on the wharf two weeks ago”
HISTORY OF PRESENT ILLNESS: Chin Sun has been waitressing in a restaurant at the wharf since freshman year at a bar/restaurant to supplement financial aid for tuition. She has very good grades (B+ to A) in college. After leaving her shift 2 weeks ago, Chin Sun was walking to the bus stop and witnessed a man beating up a woman and eventually stab the woman. Since then, her grades started slipping and she began missing classes. She reports not having interest in school any longer but wanted to graduate for her parents knowing she is this close. “This is because I don’t get enough sleep,” Chin Sun said. Not sleeping is impacting her ability to wake up in time for school, as well as ability to concentrate. She struggles to get to sleep and often wakes up startled. She also reported being so tired during the day “it interfered with everything.”
When Chin Sun is at work, she cannot stop thinking about what happened and fears leaving at night to go home. The police have taken her statement several times, but she gets a lot of anxiety when needing to talk about the incident. She believes the police get angry with her because she cannot remember some factors about the incident.
PAST PSYCHIATRIC HISTORY: Chin Sun attended some group therapy sessions in college. She had some challenges living an American lifestyle with parents who want her to maintain the culture of the “old country.”
SUBSTANCE USE HISTORY: Chin Sun drinks on weekends with her college and “bar” friends. Chin Sun reports beer bloats her, so she drinks vodka and cranberry juice mixed drinks. Chin Sun denies a problem with alcohol. She stated she has trouble sleeping several nights a week without a drink now.
PAST MEDICAL HISTORY: Chin Sun reports normal childhood illnesses. She has not had any major illnesses.
CURRENT FAMILY ISSUES AND DYNAMICS: Chin Sun’s childhood was otherwise unremarkable. She reported that she has always worked hard at school and generally was an “A” student through high school. She ran track and was involved in many activities, socializing with boyfriends, and a wide friendship circle. She reported no particular difficulties with her parents; although since this incident, Chin Sun has been very irritable. Her mood varies over the week, and she admitted to chronic anxiety and some tendency to get into “arguments” with her friends, parents, and coworkers.
MENTAL STATUS EXAM: Chin Sun is a well-dressed young person who looks her stated age. Her mood is depressed, and she lacks eye contact. Her affect is anxious. Motor activity is appropriate. Speech is clear. Thoughts are logical and organized although there seems some confusion at times. There is no evidence of delusions or hallucinations. On formal mental status examination, Chin Sun is found to be oriented to three spheres.