Daymark Recovery Case Study

Mr. Davis is a 33 year old male who presented to the ED with homicidal ideation with a plan. Mr. Davis states he has a plan to go out in his yard with a machete and kill someone. Per documentation he states, "I'm going out into the yard with my machete and I am afraid I am going to kill someone. I feel really crazy." He states he has these thoughts towards anyone that does him wrong. At the time of the assessment Mr. Davis is asleep, however becomes awaken and 4x oriented by hearing his name called. He has a history of Bipolar. He denies current suicidal ideation, homicidal ideation, and visual hallucinations. He does endorse auditory hallucination. Mr. Davis reports hearing several people telling him things. He reports his outpatient provider is DayMark and he usually go there twice a month for his Depakote injections, however has not been there since

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.

Donald is a fifty-four-year-old male with a wife, children, and several grandchildren. Donald’s symptoms started approximately thirty years ago and have been increasing in severity. Documenting the critical issues, diagnostic impressions, and treatment recommendations are imperative to successfully helping the client deal with the issues and possibly minimize the risk of future relapse in recovery. Addressing the biological, psychological, social, and spiritual aspects will help to guide the therapist through developing the most accurate treatment model for the patient.

Mr. Gillespie is a 21 year old male who presented to the ED after an intentional overdose on 20 600mg of Gabapentin. Per documentation from ED staff Mr. Gillespie reported he became angry at his grandmother tonight and tried to "prove a point." Mr. Gillespe reported to staff threatened to overdose on his on pills, however dumped them in the toilet. He expressed after making threats to overdose on his prescribed Celexa did not phase his grandmother, he proceeded to take her Gabapentin. Per documentation Mr. Gillespe has been living with grandmother for 2 weeks and before that was living with his mother in Cary. At the time of the assessment Mr. Gillespie was calm and cooperative. He denies current suicidal ideation, homicidal ideation, and symptoms of psychosis. He appears guarded during the assessment. He reports tonight his grandmother and he got into an argument over him getting a job. He reports his grandmother informed him he has to be out by Friday. Mr. Gillespe denies history of self harm. He

Pt is a 14 y/o African American male presented to NNBHC with his mother with a dx of ADHD, ODD, PTSD and Depressive D/O. Pt states that he had an episode of enuresis last night when he had a nightmare about killing his family. Pt states that when he woke up he began to have intrusive thoughts of wanting to kill his family and himself so he wouldn’t have to go jail. Pt states that recently he have been blamed for everything in the home that is missing, or goes wrong. Pt states that he has taken ownership over all the negative things in the home, so none of the his sibilings wont get in trouble. Pt states “I am pretending to be happy, this is not my family”. Pt states when he cam home from residential that his biological

Psych: The patient states that she is depressed due to “falling apart” and anxious about dying. Denies suicidal thoughts, memory loss and confusion.

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

Dr. Gentry requested an assessment for Kaitlin Bradley, an 19 year old female who presented to Randolph Hospital ER reporting suicidal ideation, with a plan, and symptoms of psychosis, and homicidal ideation. She stated " I plan to do some stupid shit". Ms. Bradley reports she has had suicidal ideation daily since the age of 10, She reports that in the past two weeks her suicidal ideation has gotten worse. She reports yesterday she was suicidal and reports if she was going to kill herself she would overdose no whatever pills she can get her hands on. Ms. Bradley reported cocaine and marijuana use, which was confirmed in her drug screening. She reports she came to the hospital so she would not harm herself. Ms. Bradley has a history of suicide

Mr. Watterly is a 15 year old male who presented to the ED via LEO under IVC by Daymark Recovery Services for homicidal ideation and auditory hallucinations. At the time of the assessment Mr. Watterly reports he sent his father messages expressing thoughts of "mass homicide and hurting people". Mr. Watterly reports feeling this way for an extent period of time. He states, "I can't even tell you when I actually started thinking like this." Mr. Watterly expressed experiencing feelings of anger and irritability without any specific trigger. Per documentation Mr. Watterly reports thoughts of slitting peoples throats, stabbing them multiple times, and snapping their necks. He admits to these thoughts in his dreams and throughout the day. Mr. Watterly

Additional, the client has met a Major Depressive Episode, which includes him currently meeting the three criteria; A, B, and C. Criteria A suggest that the client meet five symptoms during a two week time period. The client’s symptoms are as follows: depressed mood most of the day nearly every day as indicated by observation of his wife, marked diminished interest in activities most of the day, nearly every day indicated by observation of him not going to work in the past two weeks, psychomotor retardation nearly every day the last two weeks observed by his wife due to him not leaving the bed, diminished ability to think noticed by others when suggesting courses of action as to what may be helpful to him, and lastly, recurrent suicidal thoughts of death demonstrated by his irrational inquiries about an un-diagnosable disease of him dying soon. Criteria B reads that the client’s symptoms have to put significant distress or impairment in life areas of function, which the client does meet due to him not being able to currently leave his home/bed. Finally, criteria C is met because the client has to history of substance abuse or another medical condition that indicates attributable physiological effects. Although, the narrative suggests that there is history of Major Depressive Disorder, those particular episodes, I believe are not clinically attached to this particular manic episode, where he is now saying, “My skin is coming off in

Mr. Moore is a 24 year old male who presented to the ED with reports of experiencing depressive symptoms, vague suicidal ideation without a plan, and recent episodes of anxiety. At the time of the assessment Mr. Moore denies current suicidal ideation, homicidal ideation, and symptoms of psychosis. He reported to suicidal ideation would come and go, however never had a plan . Mr. Moore appears calm, cooperative and in good spirits during assessment. He reports a history of anxiety, depression, and emotional trauma by father at the age of 8 years old. Mr. Moore expressed he started noticing increase anxiety when he had to speak in large groups, present in school, driving, and engaging in social actives. He states, "Over the past 16 years my father has been out my live, when I was younger he would hit me if he felt I said anything out of line." Mr. Moore reports recent relationship issues and separation with his fiance. He reports due to him not engaging in many social actives his fiance has left him. He reports for many year going to Randolph Counseling Center for his anxiety. He reports positive results from services. Mr. Moore mention coming to the hospital last Thursday for his anxiety and bring prescribed a 30day supply of Ativan, which he reports has helped him become more stable when engaging in actives,like driving his mother's car. He reports depressive comes and goes depending on the mood he is in. He describes symptoms on occasion as feelings of

At the ER Joseph became progressively detached from reality and required the use of restraints, and chemical sedation for his safety and for ours. My training and experience indicates that Joseph has some type of mental health issue that has gravely disabled him and created a safety risk to himself and this community, as well as a danger to the public while operating a motor

Mr. Scott is a 34 year old male who presented to the ED via LEO. Mr. Scott reported to nursing staff he has not been taking medication for schizophrenia for the past 8 days because he believes the medication has not helping him with his hallucinations. Mr. Scott reports cocaine use yesterday to nurse staff. At the time of the assessment Mr. Scott is found pacing the floor of his room, However he is calm and cooperative. Mr. Scott reports he was released from a mental health facility in Chatham county. Mr. Scott mention previous hospitalization at Coastal Plains and Holly Hill. He reports a history of Bipolar, PTSD, and manic depression. Mr. Scott reports currently having suicidal thoughts of overdosing on unknown medication he has at his place of residence. Mr. Scott appears guarded and very anxious when talking to this clinician. He reports poor sleep (2-3 hours daily), experiencing flash backs of past traumas from growing up in his previous community, and visual hallucinations. Mr. Scott reports recently he would see dead bodies in the room and doors opening when he knows they are closed. Mr. Scott reports a history of suicidal ideation and attempts, the last being a month ago

Mr. Lee is a twenty-six year old African American male who was referred for Mental Health Skill Building Services by his outpatient therapist due to him exhibiting the following psychiatric problems: depressed mood (daily); feelings of worthlessness (3-6x weekly); recurrent thoughts of death (2-3x monthly); (1) suicide attempt; diminished ability to concentrate and indecisiveness (daily); and markedly diminished interest in activities that once provided him with excitement (daily). Mr. Lee reported having a history of being diagnosed with Major Depressive Disorder with Psychotic features. When asked to share some of his delusions and hallucinations they appeared to consist with typical depressive themes to include guilt, death, and voice telling

a 44 year old Divorced African Male came into Henry Ford Hospital ED as a walk-in and told the HFHS staff that he was having mental health issues he does still struggle with depression and anxiety. The consumer stated that he initially went into the hospital after his brother was shot twice in the head. At that time the client reports that he was placed on Risperdal, while at Kingswood in January, and he became a zombie at that time. He stated that he has been in and of the hospital multiple times since then, and each time, he has been placed on Risperdal and he doesn't feel that his meds were ever adjusted correctly.