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Case Study Inmate

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IDENTIFYING DATA D Data: The inmate is a 24 year old, White male, serving 5 years for POSS. On count. Sub. FEL. W/a gun/ammo. This is his first Fl DOC incarceration. He entered into the Florida Department of Correction on 4/18/2015. The curent TRD is 4/26/2018
II. REASON FOR ADMISSION: The Inmate was admitted to Lake CI MHTF on 13/22/17 from Charlotte CI due Inmate continues to refuse to eat. Inmate had been on SHOS for days, from a hunger strike, missing meals for days, and lost a lot of weight. Transferring SYSM: indicates that the Inmate was actively responding to internal stimuli. The inmate shows evidence of thought disorder, episode of disorganized thought, loose association, and flight of idea.

III. RELEVANT MEDICAL & MENTAL HEALTH HISTORY/ III. CHRONOLOGY OF TREATMENT & PATIENT'S PROGRESS: see medical chart. Mental Health Hx: PSYCH HISTORY: The …show more content…

CURRENT MENTAL STATUS EXAM: Patient was evaluated on 5/18/17 by MHP. On that day, he wore standard prison attire, eye contact and hygiene were appropriate, and he was cooperative with the interview. His mood was good with euthymic affect. He was alert & oriented in all spheres with no gross memory deficits. Speech was typical in rate, tone, and volume as well as articulated with a slight lisp. Thought process was clear, goal-directed, and future-focused, albeit concrete. He denied suicidal and homicidal ideation, intent or plan. He reported eating 3/3 of the meals & achieving 7-8 hours of sleep per.
V. REASON FOR TRANSFER: Patient is recommended for discharge from MHTF to TCU to due to inmate is no longer meeting criteria for MHTF treatment. Inmate does not present with any overt psychotic symptoms, in addition he does not appear to be a harmful to himself or others. Thus, he would most likely function appropriately on a TCU basis in which mental health providers would follow up with him on a regular basis.

VI CURRENT MEDICATIONS: Divalproex 500mg 1 tab every evening Po, Abilify 15 mg Po q

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