A Patient's Case Summary Syndrome

31 y/o AA male patient seen today for psychiatric-mental health assessment. He is awake, alert and oriented x4. He is calm, cooperative and follows commands during assessment. The patient reports he is depressed, difficulty sleeping and nightmares at night. The patient explained his depression is as a result of deep thinking from a news he received two days ago from his elder brother that his mother is ill. Stressors identified by the patient include losing his job a week ago before the news about his mother; his wife is 6-months pregnant with their first child, who currently works part-time at her present job; patient relates difficulty paying monthly bills and inability to provide adequately for his family as a man. The patient denies mood swings, suicidal/homicidal thoughts and ideation. Patient reports his spouse is at work at the moment and he does not want to put stress on his wife due to her current condition. Patient denies been hospitalized for depression or psychiatric illness; and denies family history of mental illness. Patient reports he is seeking help because he does not like feeling this way using terms of “helpless and loss of worth from his spouse”. Patient reports he needs help with his depression and nightmares before his current condition get out of hands and ruined his marriage.

The client has high motivation for treatment within MRFH. The client was diagnosed with Alcohol Use Disorder: Severe and Cocaine Use Disorder (crack): Moderate. The client sought treatment at MRFH when he realized he had lost control of using alcohol and crack cocaine. The client stated he attended the MRFH program in the 1980 's but does not remember the exact date of attendance. The client stated he was diagnosed with Mild Depression by a primary care physician when he was 56-years-old. The client reports he has no history of suicidal or homicidal attempts, and currently denies having any suicidal ideations or homicidal ideations. The client stated one to two times per week he experiences muscle tension and worrying about things that he often realizes have no significance. The client stated prior to the age of 18-years-old, "I would knock over my neighbors mailboxes and destroy their gardens, because they would make my parents aware of my wrong doings and that was way of getting them back." The client stated, there was one time that I started a fire and blamed it on my brother. I would break things as well and blame someone else. The client stated if there was an event taking place that he wanted to participate in, he would rush and complete what he was doing so he could become involved in other events taking place around him. The client stated, "I started using drugs and alcohol without thinking about what the consequences. The client appeared to be oriented to the

T.R. is a 69 year old, Caucasian female with a history of schizophrenia who presented to University Hospital Medical Center Emergency Room under Baker Act for recent suicidal attempt. According to the Baker Act report, she ran out of her retirement facility, trying to be hit by vehicles. She suffered a slight injury to her right ankle, as the slightly slightly hit her in an effort to abruptly stop the vehicle. She verbalized to police officers she wanted to die. She reported that peers in her retirement community learned about her history and had been gossiping about her. She reported increased paranoia due to this. She was hospitalized in the same psychiatric unit two months ago, after she was diagnosed with depression. Patient states the reason she was diagnosed with depression is because her two sons are not willing to talk to her. She states that she is separated and living without her family in an Assisted Living Facility. As per patient and chart review, the patient was born and raised in New Jersey and moved to South Florida. The patient currently lives in a retirement home and had to move several times to the different Assisted Living Facility, due to her paranoia and delusional behavior. She is currently retired and reports that she used to work from home as a home health aide. She has two sons and tries to maintain a good relationship with them, but denies any contact with them. She reports the biggest stressor is basically a relationship with her

The patient was a middle aged man who was diagnosed in his early twenties with what is now called bipolar. He is a known marijuana user and a binge drinker however he has been clean for around 1 year; then in his mid-thirties he was diagnosed with paranoid schizophrenia. He had come in through the emergency department after an unsuccessful suicide attempt and had been on the unit for nearly 5 months; he was due for discharge by the end of the week.

Presenting Problem: Zachary has required x3 inpatient hospitalization within a 6 month time frame. Zachary struggles with communication in the family dynamics that generally evoke anger, irritability, physical aggression, and suicidal statements. Most recently he was admitted at NNBHC due to SI, HI statements and AWOL behaviors. He is not compliant with medication compliance or participating in outpatient treatment. He states overall mood has been on and off with periods of feeling down. He reports decrease interest in activities.

For a conscious patient, the physician asks a variety of questions designed to check cognitive

Background information: John Smith is a Caucasian male in his mid-thirties who is living alone in Truman. He was at his VA appointment in Jonesboro when the therapist admitted him to the hospital for suicidal ideation. John Smith has an ongoing struggle with psychosis and suicidal ideation for the past couple of years. The patient reports he has received outpatient and inpatient treatments for a couple of years. Currently, the patient is unemployed and his major source of income is Veteran’s benefits. Pt reports he has no legal matters or barriers to treatment. John’s strengths include good family support system, utilized health care systems, and motivated for treatment. However, his weaknesses include psychosis, unable to sleep, impulsive, and sad. His interests and hobbies consist of spending time with his family and playing with his cat.

Setting the Stage: Patient 1 is an 87 year old retired man who arrived by ambulance. His last admittance to the hospital (from the nursing home that he lived at) was 2 months ago. According to his medical records, he had a history of peripheral arterial occlusive disease and deep vein thrombosis, and came in due to leg pain and a urinary tract infection. While the patient did not have a diagnosed neurocognitive disorder, the patient appeared delusional, and told the occupational therapist that he (the patient) was a retired occupational therapist, but had told the physical therapist the previous day that he was a carpenter. The patient was being treated for depression and anxiety with medications.

Mr. Enochs is a 50 year old male that presented to the ED by IVC paper work from Daymark Recovery Services. Patient reported depressive symptoms and SI with a plan. Mr. Enochs stated : "I'm worried about my family and not being able to support them." He reports he has been unemployed and unable to find a Job. Mr. Enochs reports in the past 3 days consistent worrying about his sick wife, kid, and having continuous panic attacks. Mr. Enochs reports racing thoughts. He stated: "my mind never shuts down."Mr. Enochs reports he has been thinking about walking into traffic or falling into a hole at a construction site to take his life. Mr. Enochs stated: "I think if I was dead I could help my family financially." He reported only having 3 hours of

She was hospitalized multiple times in psychiatric facilities (2001-2002) for suicidal ideations and attempt, severe depression and anxiety, and hallucinations for self-harm. She was under “aggressive psychiatric and psychological treatment” (2004-2012) without improvement. She had a below average intellectual functioning and was unable of managing money.

SR is a 45 year old, single, African American male, who lives with his family in an urban area of Columbus, GA. SR is currently unemployed, but is on disability. SR is presenting to see if a higher level of care is needed for his presenting symptoms. A local outpatient community service board referred SR, after a routine appointment with his outpatient therapist because of reported aggressive behaviors, to include homicidal threats, with multiple plans, by his family. While at the appointment his outpatient therapist reports that the client was rambling, having racing thoughts, rapid and frequent mood swings and severe paranoia. SR reports that he is easily agitated and has anger outbursts that accompany his mood swings. He also reports severe bouts of depression that leads to decrease in sleep and appetite, as well as helpless, hopeless, and worthless feelings. Client reported feeling like people were talking about him, and laughing at him, while at home with his family, he also feels that his family are out to get him, and his money, onset, x2 weeks. SR also reported current active homicidal ideations on 10/31/16 with a plan to shoot his friend who stole money from him. Client reports onset for H/I was 10/29/16. SR has no previous homicidal attempts. Per family, SR is very impulsive and spends his money on gambling and drugs. SR also has a 15 year addiction to cocaine, which he feels he can’t kick. SR has tried to stop in the past, but he always

Client is a 35 year old African American female with an 12th grade education level who presented with signs and symptoms of forgetfulness, depression, severe anxiety, stress, uncontrollable mood swings and difficulty making decisions. During the assessment, the client struggled with bouts of crying triggered by memories of her past. The client was recently hospitalized at VCU Hospital for signs and symptoms related to a panic attack. The client has been given the diagnosis of Major Depressive and Anxiety. The client has been prescribed Prozac. Currently the client does not have a PCP or psychiatrist.

a 24 yo SAAM who presented independently to COPE today. He stated that he is homeless and seeking transitional housing, however he also is exhibiting symptoms of psychosis. Patient is having command hallucinations to hurt himself and was observed responding to internal stimuli during assessment. Patient denies paranoia, but does have some delusional thinking. He stated sleep/appetite are decreased, grooming/hygiene poor and is unable to contract for safety at this time. He has had multiple suicide attempts, and showed me an old scar on his wrist from "2015 I used plastic from a container, I didn't know how to do it the right way". He also showed me several cuts on his chest that appear fresh, the nurse was able to look at them and determine

The patient expressed she has no current suicidal ideation or homicidal ideation. However, she admitted to suicidal ideation in the past, right after her breakup, approximately two months ago. She expressed that she wanted to hurt herself and had a plan on how to do so, but did not think she could go through with it. Her plan was to overdose by taking her mother’s

Tom is a 46 years old male, 187cm tall and 73kg. He appeared to be very anxious with drops of sweat on his face and hands, which felt cold and clammy.