Obstetric Case Study Examples

SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married.

CHIEF COMPLAINT: This is a post op note from a procedure performed July 21, 2015 by David Lin, MD.

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.

The writer met with 5 y/o AAM brought to Sinai Grace by EMS due to suicide attempt drinking and took overdose of pills. The consumer also admits to prior suicide attempt three weeks ago. The consumer live with family and has income. The consumer present with flat affect, depressed, agaited and has limited insight into the need for treatment. The writer ask the consumer about what was going on in his life to make him attempt suicide. The consumer states it was life stressor and report that he was in a car accident a few weeks ago. The consumer admits depression, anxiety, limited insight into the need for treatment and impaired judgment and he has some desire to improve on his current situation. The consumer admits to drinking alcohol daily

Mr. Saunders is a 60 year old male who presented to the ED via LEO under petition by his niece, Rachelle, for allegedly putting a gun into his mouth, him putting a gun in another individuals mouth called "legs", and increasing alcohol consumption. At the time of the assessment Mr. Saunders is calm and cooperative. He denies suicidal ideation, homicidal ideation, and symptoms of psychosis. Mr. Saunders reports he has been depressed for several months and has been binge drinking alcohol. He reports relational issues with his wife has been the primary stressor contributing to his distress. He express feelings of hopelessness, worthlessness, irritability, and isolation. He does admit to informing a friend, William, he see no reason to leave if he can not be with his wife. Patient does not appear to be exhibiting signs of agitation,

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

Patient states that he was on unit in April of this year. Patient states that after discharge he tried to get into a program (Salvation Army in Manhatten), but there were no beds available. Patient reports that he went back to his same enviromemtn, Jersey City and started drinking and using heroin. Patient said that he had no health insurance so he was unable to fill his prescription. Patient reports that he applied for Medicaid and is currently waiting to see if he is going to be approved. Patient stated that he would like to go to Meadowview in Seacucus. Patient states that he reason why he uses is to self-medicate because he has no insurance. Patient stated that he would like to get into long-term rehab that does not require him

On 7/27/2015, HOH and client attended to ILP meeting with their daughter Emily. Child was observed well dressed for the weather. Client explaining to cm that her floating hospital was cancel and she doesn’t know the reason.

The counselor met with the patient for her scheduled Addiction Severity Index assessment. The patient is a 54 year old black male. The patient states he is single with no children. He report currently lives with sister in law of his decease brother. The patient reports having a 14 years of education however no degree. The patient report receiving disability for mental health disorder. The patient reports he is currently not on probation. The patient reports he last use Cannabis 7/17/15 and started using at the age of 13 and smokes 3 to 4 times a week at least 2 joints. He also report using Alcohol 7/20/15 a 40oz beer and usually drank a couple a day. 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 Monday, July 27, 2015 at 02:30p

Due to an increase in depressive symptoms, suicidal ideation, homicidal ideation, poor insight, poor judgement, poor impulse control, harm to self, patient does meet criteria for IVC and inpatient hospitalization. TACT consulted with Dr. Osborne

Wife reported his multiple providers shared their notes. Mrs. Overman reports 4 year ago when his father died, Mr Overman became depressed and started to abuse opiate and other pain pills. She reports his PCP as recommended him to attend substance abuse treatment. He is not currently attending any outpatient services for substance abuse. Mrs. Overman states out of the 15 year she has known him he has not attempted to harm himself. She reports At the time of the assessment Mr. Overman currently denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He denies any mental health history or attempts to harm himself. He reports attending substance abuse treatment at 2X Bethal Colony. He reports yesterday his friends gave him something to take for his pain. Mr. Overman reports going to Walmart with all his medication and his

Deborah F. is a 53-year-old female who had been admitted to the Chemical Dependency Rehabilitation Program at Sharp Mesa Vista for the treatment of alcohol dependence and pain disorder. Her history includes several disorders that are a cause of her pain including lupus, fibromyalgia, spinal arthritis, interstitial cystitis, shoulder pain, and multiple foot surgeries. According to her chart, she had been drinking two bottles of wine daily for almost two weeks in attempt to forget about her increasing pain. She is currently on voluntary detoxification and is considered a high fall risk. Her plan of care includes a series of medications that are prescribed for her pain and medical problems. Along with her treatment, Sharp Mesa Vista Hospital implements a treatment plan for all patients in the CDRP, which is referred to the 12-step treatment. One of the main activities that are included in this treatment is regular participation at group meetings that are conducted each day. The concern with Deborah is that she has been continuously refusing to attend the groups during her three-day stay at the hospital. She believed that attendance would not help her with her drinking issues and believed that even groups such as Alcoholics Anonymous would not benefit her. Based on the nurses ' report, it seems that she will not be discharged in the near future. One way that she will be able to progress in her recovery

1. The nurse is asked to implement a new, complex, and invasive procedure and is concerned that this may violate the state’s nurse practice act.

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

The advancement of medical technology has made it possible to detect medical abnormalities while a child is still a fetus and can create difficult choices for parents to make if severe anomalies are discovered. There are many theories regarding the moral status of the fetus that can be applied when deciding how to proceed if these abnormalities are detected. In the fetal abnormality case study, Jessica, Marco, Maria, and Dr. Wilson each have varying opinions on what course of action to take based on these different theories of moral status.