SCENARIO FOR CASE PRESENTATION

Patient Information:

• Name: Sarah Thompson

• Age: 8 years old
• Gender: Female
• Background: Sarah is an 8-year-old orphan who lost both of her parents in a tragic car
accident six months ago. Since then, she has been under the care of her maternal
grandmother, Mrs. Martha Thompson. Sarah was deeply attached to her parents and witnessed
the accident, which has left a profound impact on her emotional well-being.

Presenting Complaint: Mrs. Martha Thompson brings Sarah to the clinic with concerns about her
behavior and emotional state following the traumatic loss of her parents.

History of Present Illness: Sarah's grandmother reports that following the accident, Sarah has been
experiencing recurring nightmares, often waking up in a panic. She has also become withdrawn,
preferring to spend long hours alone in her room. Mrs. Thompson notices that Sarah seems easily
startled, especially by loud noises or sudden movements. Sarah's school performance has also
declined since the incident, with her teachers noting increased difficulty concentrating and
participating in class activities.

Past Medical History: Sarah has no significant past medical history. She was previously a healthy and
active child before the loss of her parents.

Psychosocial History: Sarah was deeply attached to her parents and had a close-knit family
environment before the accident. Since then, she has been living with her grandmother, who provides
her with a stable and loving home environment. However, Mrs. Thompson has noticed Sarah's
struggle to adjust to life without her parents and is concerned about the impact of the trauma on her
granddaughter's mental health.

Family History: There is no significant family history of psychiatric disorders or trauma-related

conditions.

Physical Examination:

• General: Sarah appears well-nourished and appropriately developed for her age.
• Vital Signs: Within normal limits for her age.
• Neurological Examination: Grossly normal.