Assignment task:
Case of Mateo
Identifying/Demographic Data: Mateo is a 7 year old male in the third grade. He lives in Houston, Texas with his parents. He is the only child to two parents, both of whom have completed post-graduate education. His parents are originally from Guatemala and relocated to the United States when Mateo was 6 months old for job opportunities. Mateo is an intelligent and caring young boy who presents with significant potential to excel academically. Need Assignment Help?
Chief Complaint/Presenting Problem: Mateo was referred for an evaluation because his parents and teacher indicate that Mateo is restless, and often requires reminders to help him stay on task. He is described as "constantly running around" and presenting with difficulties listening and following instructions.
History of Present Illness: Mateo enjoys spending time with his friends, and participating in physical activities such as swimming, running and skating. He also enjoys participating in social events, and is often invited to play dates and birthday parties. While Mateo interacts well with peers his own age, his parents believe he is easily led and influenced by others. Mateo does get upset when he does not receive recognition or feels that he has been ignored. His teacher notes that he sometimes acts 'socially immature', and that he often demonstrates attention-seeking behavior.
Mateo has difficulty focusing and sitting still in class. He is able to 'hyper focus' on some activities of interest however he often has difficulty sustaining his attention at school. Mateo has been known to blurt out answers and interrupts other students in the classroom. His mother reports difficulties at home with following routines and remembering instructions. His parents describe emotional reactivity as well as confrontational behaviors demonstrated both at home and at school. His teacher notes that Mateo is defiant towards listening to instructions, but generally interacts well with his peers. He is easily frustrated and emotionally impulsive - Mateo has had several incidents of hitting, crying outbursts, and inappropriate behavior. Behavioral concerns with aggression, lying, arguments, and disruptive behavior were noted in his pre-school program at age 4. Each school year since teachers has reported incidents in the classroom.
Past Psychiatric History: This is the first evaluation for Mateo. It is noteworthy that he did not know his address or home phone number, could not print his surname, and recognized only a few pre-primer words.
Substance Use History: None reported
Past Medical History: Mateo has been vaccinated with all the needed vaccinations to attend school. There are no noteworthy illnesses to report.
Family Medical And Psychiatric History: Mateo' parents report some history of mental illness in the family. His maternal grandmother was diagnosed with depression. Mateo has always had challenges falling asleep, and sometimes finds that he wakes up in the middle of the night. When he wakes up he finds that he has a difficult time getting back to sleep - sometimes staying awake for as long as an hour and a half.
Mental Status Exam: Mateo is age appropriate in size and structure. His appearance is clean and neat. Mateo is an active child and interacts with his parents appropriately. There does not appear to be any underlying overtones between the parents and Mateo. Mateo did not have any problems separating from his parents when being interviewed. Speech is appropriate for child's age. Mateo' mood is in normal range and congruent with his mood. Affect was appropriate. There were no hallucinations or delusions. There were some challenges with Mateo's judgment and insight.