Mr Moore Case

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 patient was admitted to the hospital by her daughter after discovering that she had abandoned her medication and was significantly experiencing adverse effects from the withdrawal. The patients’ medical history included renal dysfunction, anemia, malnourishment, back pain, and a family history of mental health. The patient has a psychiatric history of being previously placed in the same clinical structure eight months ago due to related issues including the failure to take her medication and increased levels of mental health conditions that led

Choices, whether small or large, play an important factor in the paths people take in life. In The Other Wes Moore, there are two men with the same name who turn out very differently; today, one is an accomplished scholar and decorated veteran, while the other is a convicted murderer serving a life sentence in prison. But they grew up in very similar circumstances; both grew up fatherless in heavily drug influenced neighborhoods and often ran into trouble with the police. In the search of finding what led him and the other man down such different paths, Wes Moore finds and shows in The Other Wes Moore that it is the choices a person makes that determines their fate in life.

A displayed feelings of apprehension and became less co-operative during the initial clinical interview. She additionally displayed thoughts of inadequacy . She moved back to her parent’s house when she began getting panic attacks and was housebound through fear of inducing a panic attack. As a result of this, she became overly reliant and attached to her parents, who provided emotional, financial, and decision making support.

The client is a 35 year old African American female who presented as open and anxious during the assessment. In 2011, the client was diagnosed with Bipolar and Anxiety. In 2015, the client was hospitalized for 7 days at Richmond Behavioral Health Authority. The client was admitted due to symptoms of irritability, lost track of time and blacked out. The client was prescribed Seroquel and Topamax.

The patient is a 34 year old black male. The patient reports he is single with 3 daughter ages 3, 11, and 13. The 3 year old live with him. He reports currently live with his mother and brother. The patient reports he has 14 years of education however has not received his degree. The patient reports being on probation for Injury to a child for the next two years. The patient is scheduled to be complete his probation in September 2016. The patient reports Cannabis is primary substances and his last use July 20, 2015. He stated on that day he smoked about 5 joint. The patient also report that he tried Xanax . The patient denies any issues with HI/SI. Patient also reports he is taking his medication as prescribed. The patient appear to be in the pre-contemplation stage of change. The patient next scheduled individual session with the counselor is on Thursday, July 30, 2015 at

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

Mr. Goins is a 52 year old male who presented to the ED via LEO following a 4 day binge on alcohol and requesting help with his dependence. Mr. Goins reports he moved to Asheboro recently and found work, however recently lost his job. He reported a history of alcohol use and depression. Dr. Keith requested an assessment on Mr. Goins.At the time of the assessment Mr. Goins denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He reports 5 days ago he became unemployed. Mr. Goins reports his fiance who is his primary support system left town to go to a doctor appointment in their home state of Georgia. He reports binge drinking for the past 4 days attempting to cope with his recent stressor. Mr. Goins reports calling his fiance last night an expressed to her he need help. He states, "I told her I felt at the time no reason to live." Further Mr. Goins stated, "I just had too much in me last night, I had about 14 of them airplane bottles." Mr. Goins denies a history of self harm. He does report a prior hospitalization for depression in Georgia. He also reports a history of attending substance abuse treatment, which was a positive experience for him.

will schedule an appointment to discuss and create a budget plan. Patient is currently free from all illicit drugs, which has helped her Adderall medication to be more beneficial. Primary Counselor will encourage Pt. to follow through with all mental health appointments. Counselor will prompt Pt. to develop a positive self-image. Pt. has denied having any auditory or visual hallucinations during the last quarter as evidenced by group and individual session notes. Pt. has had some setback in achieving her goals of decreasing her family conflicts and resolving intimate relationship issues. Counselor will encourage Pt. to attend the AMS parenting group and share her expectations regarding having a more functional family unit. During the next quarter therapy sessions, Counselor will utilize role-playing, role reversal, modeling, and behavioral rehearsal to assist Pt. in order to develop positive ways to resolve conflict with ex-husband. Pt.’s current treatment plan goals focus on opiate use disorder, financial, mental health services and parent-child relational problems. During the upcoming quarter, current goals will continue to be

Pt. has been in the AMS program for 2 years. Pt. has had no positive UDS results for two years. Pt. is on a dose of 150 of methadone and he is responding as expected to his prescribed medication. Pt. demonstrated responsible attitude by attending monthly AMS groups faithfully. Pt. has discontinued all illicit drugs use and now he has used financial income in a more self-sustaining manner. Pt is effectively addressing this area by making regular payments as scheduled. Demonstrates treatment maturity and appropriately participating in medical treatment services. Pt. was taught calming strategies, such as relaxation and breathing techniques as indicated by previous counselor documentation. Pt. was assigned to this writer caseload and counselor

Client reported feeling down within the last month and using heroin to cope. Client also reported feeling better and motivated towards the end of the month. Client completed a Beck Depression Inventory in which he scored a 6 indicating normal ups and downs. Client VA records confirm a diagnosis for PTSD and the medication list includes, Sertraline and Setraline HCL, as well as methadone to which the client appears compliant. Client reported he is medication compliant. Client denied any S/I or H/I.

D-The patient was placed on HOLD to see this writer to address her no show for counseling on Friday and missed dose as well. According to the patient, she had transportation issue. The patient admitted that she relapsed by using crack cocaine-$20 bags by smoking. Addressing the relapse is due to stressor of her current residency with her "baby-daddy," according to the patient. Alternatives were discussed. The patient asked this writer for assistance again for the contact number to CHR and CVS of which this writer provided. In addition, this writer questioned the patient about her living situation as she reported about it being a stressor in her life. According to the patient, she is no longer residing at her "baby-daddy" resident as she reported

History of Present Illness: The patient has been seen in this clinic since 2016. She is diagnosed to have ADHD, Bipolar II disorder, Generalized Anxiety disorder, Alcohol and Cannabis use dependence. The patient has struggled with separation from an abusive ex-husband, who is currently

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.

296.32 (F33.1) Major Depressive Disorder, recurrent episode, moderate severity, with anxious distress. Ms. Client meets eight of the nine diagnostic criteria for Major Depressive Disorder (MDD). Specifically, during several periods of time she experienced depressed mood, diminished interest in things she enjoyed to do, hypersomnia, psychomotor agitation, fatigue, feelings of worthlessness, decreased concentration, and suicidal thoughts without intent. Additionally, as Ms. Client expressed, these symptoms are source of continuing distress and interfere with her academics and social functioning. Also, her symptoms started four years prior to the psychological assessment and persisted intermittently since then, lasting for several weeks to several months, with the most recent period of extended length (enduring two weeks) approximately one year ago. Since the last episode she has experienced these symptoms for two to three days at a time. Although the last episode that met the criterion of two weeks duration occurred approximately a year ago, the symptoms have not disappeared, but they occur periodically since then and when they do, they cause considerable distress and impairment in functioning. Thus, the disorder cannot be coded as ‘in partial or full remission’. The specifier ‘with anxious distress’ was given, because Ms. Client reports feelings of difficulty in concentration because of worry and restlessness.