Cli ASBR History
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ScribdTranslationsCli ASBR History
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ScribdTranslationsPSYCHOLOGICAL CLINICAL HISTORY
I. GENERAL DATA:
Names and Surnames A.S.B.R.
Sex Female
Age 14
Date and place of birth October 12, 2005
Degree of Study Secondary
Occupation Student
Current Address Urb. San Joaquín M – 22 (4th stage)
Marital Status Single
Religion Catholic
Informant The same patient and the father
Interview Date October 27, 2019, November 2 and 16, 2019
Examiner Waldo Sánchez Mendoza
II. REASON FOR CONSULTATION:
For internships in the course of Evaluation and Clinical Diagnosis
III. CURRENT PROBLEM:
The patient expresses a huge desire to leave her house, which she feels in
bored occasions of being in it and that her parents do not allow it because they do not have
still the age for it.
IV. BEHAVIOR OBSERVATION:
Patient oriented in place, time, space, and person, presenting a language
fluid and coherent. She was cooperative, showing no resistance during the
development of the dialogue. However, he maintained a shy attitude that became
evident in the low tone of his voice, little eye contact, and in his posture
slightly bent.
The patient is a young woman of slender build, with a brown skin tone, black and straight hair.
black and almond-shaped eyes, straight nose, thin lips, and average height.
Dress simply and in accordance with the season.
V. FAMILY HISTORY
- DAD: The patient states that her father is 42 years old, dedicated to service.
maintenance in an agro company. It has a stable character ('it almost does not')
"Angry a lot.") He doesn't drink or smoke; and often complains about back pain.
he also mentions having more communication with him and with his sister
small
- MOTHER: The patient reports that her mother is 42 years old, dedicated to household chores.
from home, he is cheerful (although sometimes he gets annoyed). He neither drinks nor smokes; and in
health often complains of headaches. Likewise, he pointed out his little
communication with the mother although it is noted that it is her brother who shares
more moments with her.
- CHILDREN: The patient states that she does not have any
- HUSBAND (WIFE): The patient states she does not have any romantic relationship.
- SIBLINGS: The patient states she has two brothers. One male, 18 years old,
who is studying administration. Indicates being reserved. Drinks in
occurrences in moderation and does not smoke. Did not indicate any relevant illness. And
in relation to his interaction with him, she described it as distant and respectful
the mutual space, very few are the moments in which both
they play.
Then there is her 8-year-old sister with whom she shares most of
time (both at school and at home). She describes her as a healthy girl,
mischievous and spoiled by her parents.
VI. FAMILY HISTORY
-PREGNANCY: No information that I remember on my part. Her father, on the other hand, points out
what was normal.
PART: The patient does not provide any information, while his father points out
normal and breastfed until the year and 8 months
approximately. He also noted that there was no rejection of the food.
solid.
PSYCHOMOTOR DEVELOPMENT: According to what the mother stated, the patient
had a psychomotor development within normal parameters (walking at
a year and two months, and speaking at a year and a half) and without health problems.
-CHILDHOOD: The patient does not remember any relevant information
SCHOOLING: The patient is described as an average student.
communication your favorite subject. Acknowledge your limitations and strengths for it
that at times accepts the leadership of a more advanced colleague
during the formation of the work groups.
She also mentions having a best friend with whom she shares her experiences.
only the school environment, since his parents do not allow him to go out of
house.
-ADOLESCENCE and YOUTH: Currently, the patient indicates having a
routine life, focused on studies and not going out much when
the opportunity is given to visit family or to go shopping in
your mom's company
SEXUAL LIFE: She indicated that she is calm and not particularly interested in any guy.
Her first menstruation started at the age of 13, she noted that she was informed but
Still, he got scared. And regarding its periodicity, he indicates that it is of type
irregular.
And her opinion regarding men is that they should be more mature.
-ADULTHOOD: No data to record.
DISEASES: The patient reported having suffered from Hepatitis.
He loves spending hours on TV being his
favorite programs on weekends "The WhatsApp of JB" broadcasted by
Latina and the Disney Channel throughout the entire week.
WORK AND OCCUPATION: The patient indicates that ordinarily she
She takes care of some household chores when she comes back from school.
VII. GENERAL CHARACTERISTICS OF BEHAVIOR:
PHYSICAL DESCRIPTION
The patient is a young woman of slim build, olive skin, black hair and
slender, with black almond-shaped eyes, a straight nose, thin lips, and tall
average. Dress simply and in accordance with the season.
LEVEL OF AWARENESS
His level of consciousness allows him to discern his actions between good and evil.
emotional_state
His emotional state is balanced and of the euthymic type.
SOCIAL INTERACTION
It is limited to the family environment and on the rare occasions they interact.
with someone she remains reserved (this according to what she has expressed herself
patient).
When he is at home, he usually moves not very far from it.
approximately four blocks.
VIII. COGNITIVE PROCESSES
ORIENTATION, SPACE, TIME AND PERSON
The patient engages in a fluent dialogue, showing signs of good orientation.
in place, time, space, and person.
ATTENTION AND CONCENTRATION
Her attention and concentration are normal, showing attentiveness to each question.
during the development of the interview
PERCEPTION
The patient retains her ability to discern stimuli.
MEMORY
The patient shows no alterations in this area, she is able to evoke facts.
from the distant past and the more recent.
-THOUGHT
The patient manages a real thought that is in line with her context. There is no
no alteration whatsoever in this area
LANGUAGE
The patient presents fluent speech with a weak intensity voice.
low tone and timid timbre.
INTELLIGENCE
The patient has a normal intelligence level.
IX. AFFECTIVE LIFE, CHARACTER AND ATTITUDES
MOOD
The patient presents a stable mood.
AFFECTS AND FEELINGS
Shows understanding of the rules imposed by his parents and
shows obedience with them. Maintains a closer relationship with his/her
little sister, she usually helps her with her homework and plays with her brother
prefers to keep her distance without it meaning that she doesn't get along with
He makes it clear that he holds no negative feelings towards him.
-CHARACTERISTICS
The patient is characterized by her phlegmatic nature, showing little expressiveness.
in their responses, kindness in dealing, persistent in their performance
school. But also, avoid as much as possible depending on others, it is
collaborative and tries to remain patient.
- ATTITUDES
Their attitude tends to be rational, collaborative, and focused on ...
activity.
X. EVALUATION
Observation and interview techniques
XI. DIAGNOSTIC IMPRESSION
Z 62.1. Parental overprotection
XII. FORECAST
Based on the diagnostic presumption, the development of a possible
fearful and anxious personality with low tolerance for frustration that
make react impulsively. It would also lead to the construction of a
there is a lack of confidence in their abilities, affecting their capabilities to
to face one's own problems.
XIII. RECOMMENDATIONS
Individual therapy with the young woman
Family therapy
……………………………………………
Company
Waldo Sanchez Mendoza
(Psychology Student)