Notes

Clinical Interview Notes
Patient: Mayra Valladares Pavon
04/26/2021
Introduction
Ms. Pavon appeared for the interview with a legal assistant. Presentations were made between Ms. Pavon and the translator. Ms. Pavon was told that the translator would be in charge of administering the tests after the clinical interview. Dr. Greve informed Ms. Pavon that she was sent here for a psychological evaluation and that he had been hired by the defense to do an evaluation. The doctor explained to Ms. Pavon that he wanted to talk to her about the process, he wanted her to explain her accident, what happened to her, and what she has done to feel better. Dr. Greve wanted to know about her life before the accident as well. He informed Ms. Pavon of the three things he likes to tell all of his patients. The first thing is that he would like Ms. Pavon to be as accurate and honest as possible. There should be no exaggerations, but also no undermining of her current state of being. The second is that she would undergo testing that is going to be tiresome and simply do the best she can. The third thing Dr. Greve wanted Ms. Pavon to know was that he is a psychologist and that he would be asking some questions that might seem strange. If Ms. Pavon does not understand something or is confused, she can ask the doctor questions. All of this was translated from English to Spanish, Ms. Pavon agreed to each part.
Background
Ms. Pavon is from Honduras and has lived in the United States for 8 years since December 2012. Upon arriving in Houston she immediately went to New Orleans. Ms. Pavon recounts that the accident happened on May 12th, 2018 around 4:00 PM. Ms. Pavon explained she was with her 2-year-old daughter driving 45mph on Highway 59 in Mandeville. On her left side was a Popeyes. Suddenly a gray truck pulled out and was hit by an oncoming white truck. The gray truck turned over several times and hit Ms. Pavon's (Blue Mazda) car. Ms. Pavon lost control of her car and it spun several times before crashing into the wall. Ms. Pavon felt dizzy and half-conscious and unconscious. The car's airbag exploded and burned Ms. Pavon's face, she was struck on her chest by the steering wheel, and injured her left knee. Ms. Pavon waited for the paramedics to arrive because she could not get out of her vehicle. She described that everything happened very fast. Ms. Pavon's life has changed a lot since the accident. She has had two surgeries on her left shoulder and her left knee. Ms. Pavon has problems with her neck and her left hip as well. Ms. Pavon explained that it has been a very difficult time without the support of her family in the United States and to take care of her daughter. Ms. Pavon remembers being in the hospital after the accident and receiving medical attention.
Ms. Pavon had surgery on her left shoulder and knee. The shoulder surgery helped but her recovery time was very difficult. She is also awaiting a second surgery on her left knee. When sitting for long periods of time, Ms. Pavon's knee hurts and she limps. Ms. Pavon has received painful injections in her neck. She attends physical therapy and has been told by her doctors that she will need therapy for a long time. Some of the side effects from the injections include dizziness and pain at the injection site for 3 days. The injections help for up to 2 months. Other difficulties that Ms. Pavon experiences are neck and knee pain, insomnia, headaches, forgetfulness and concentration problems that started around a year ago, depression and sadness, anxiety, and mood changes. Ms. Pavon said her husband noticed she gets irritated very quickly. Ms. Pavon has found that she is forgetting things and has to make a shopping list when she goes to the supermarket. Ms. Pavon does not get ready to go out or socialize like she used to. Ms. Pavon has been doing psychotherapy through Telehealth. A legal assistant helps with translating. Ms. Pavon denies feelings of wanting to take her own life but admits that she has been very depressed. Her situation has been very difficult financially. She has to pay someone to take care of her daughter and it is difficult for her to find a caretaker. Ms. Pavon does not work and worked very shortly before her accident because she has to take care of her daughter. Ms. Pavon uses religion as a form of support. Ms. Pavon's daughter has level 3 autism. Her daughter receives classes and goes to school. Some of her challenges include pulling her hair out, forcing herself to vomit, and scratching herself and other people.
Ms. Pavon has a 16-year-old son in Honduras. She said that she feels like she abandoned him because she does not have the financial means to bring him to live with her. Ms. Pavon takes care of herself, slowly cleans and cooks, and does not do yard work. Her husband takes care of the finances at home. Ms. Pavon started driving around her neighborhood to overcome her fear of driving. When asked if she has worked since the accident, she said no. When asked if she had ever lost consciousness before the accident, she said no. When asked if she had suffered some kind of fall that injured or hit her head, Ms. Pavon said no. When asked if she has had a concussion, seizure, stroke, brain infection, or brain surgery she said no. When asked if she had seen a psychologist before the accident, she said no. When asked if she suffered from high blood pressure, she replied that she suffers from low blood pressure. When asked if she had diabetes, she said no. When asked if she suffers from a heart condition, she answered no. When asked if she has had or has cancer, she said no. When asked if she uses tobacco or tobacco products, she said no. When asked if she drinks alcohol or if she drank before the accident, she said no. When asked if she uses or has used drugs, she said no. When asked if she has had anxiety, she said that she has always had anxiety before going to sleep and that she used to take medication to help her sleep but now does not. In Honduras, Ms. Pavon was a single mother and lived with her sister. She has a younger brother and an older sister. Her father is still alive, and her mother died 16 years ago when she was living in Honduras. In the United States, Ms. Pavon has been with her partner for 8 years. Ms. Pavon finished the sixth grade in Honduras. Her aspiration is to take English classes. Ms. Pavon cleaned an office for 2-3 hours nights for a short period of time. In Honduras, she sold fruits and juices with her sister. Ms. Pavon has never been in trouble with the law and has never been to jail. Ms. Pavon has gained weight since the accident. The doctor asked Ms. Pavon if she had any questions for him and she said no. Ms. Pavon was informed that the clinical interview had concluded and that the translator would be her psychometrist.