Identifying information:
The client is a fifty-two year old, White, upper class, female. The client lives with her husband, near New Carthage University, where her husband is a tenured professor. Her father is the president of the university. Martha is a homemaker.
Presenting problem:
"I cry all the time; but deep inside, so no one can see me.”
Emergency medical personnel have admitted the client to inpatient treatment after she suffered from acute alcohol poisoning. Staff was alerted to a possible ongoing substance use disorder when delirium tremens, hallucinations and withdrawal symptoms were present within eight hours following her treatment for alcohol poisoning. She was referred to me in order to be assessed for long term care. Client says she has eight to twelve drinks a day, never having fewer than five drinks. Client has admitted depressed mood, emotional reactivity as well as interpersonal problems with family, friends and with her husband George.
History of presenting problem:
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Client indicates that she does not have a history of hospitalizations, but does occasionally spend time in a “rest home.” Upon further exploration it appears that the “rest home” she visits functions as a private hospital or spa style detoxification and alcohol treatment facility where psychiatric medications (e.g. Librium, Valium, Clonazepam) are prescribed by health care professionals. The client has been nine times in the past 30 years. Although initially she insisted it was just a place to rest and get fresh air Martha later referred to it as a place that she was “shipped off to” when she was “losing her marbles,” “couldn’t cope” and “just wanted to drive her car off a cliff.” It is unclear if her symptoms of depression and potential suicidal ideation are historical in nature, ongoing or alcohol
Client comes to treatment because she has been mandated by the court to receive services for her drug and alcohol usage. Client self-reports an extensive history of drug and alcohol usage, as well as, issues with controlling and maintaining her anger. Client is more concerned with her anger issues then her drug and alcohol usage. Client feels that if she can control her anger then she will not have to turn to drugs and alcohol. Client appears to be self-medicating with drugs and alcohol.
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.
At age 77 J.B. is a healthy and active woman, who spent her life before retirement as a nurse working at Shriners Hospital for Children. Her mental health and wellness as she has aged has stayed strong. She has full cognitive function and is able to make sound decisions about not only her life, but others that she may care for. Her mental health I feel keeps her strong physically along with the fact that she stays active with her husband and grandchildren. Functionally she has no problem mentally or physically going about her everyday activities or any other activities that are required of her. Culturally she is versed in many different cultures as she spent much of her career caring for people as a nurse and working in hospitals. Her
Client was given table and 4 chairs, coffee table, 1 side table,2 chairs lamps-inflatable air mattress very uncomfortable; by a friend.
Client (AM) is a 20-year-old heterosexual African American female, born in Durham, and currently still resides there. Her primary language is English. She lives with her 13 moth old child (NM) in a one-bedroom apartment. The client is unemployed and currently receives SSI benefits. AM resides in subsidized housing because of her social security income. Client did not finish high school and has no desire to do so.
Mental Health Update: Client was diagnosed with Clinical Depression and client reported she wasn’t attending her mental health counseling at BATF (“Bridging Access to Care”).
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
Following this step, finding out the reason behind Sheila’s refusal and failure to take prescribed medication is imperative as the medication is to help treat her mental illnesses. Focusing on her medication and mental health is crucial as it ties in with her addictions and her overall well-being and her behaviour towards
The point at which the client’s symptoms were most extreme was towards the end of her alcoholism, which was in her early thirties. She used humor, felt incomplete and fragile, oversensitive to other’s reactions of her, felt the need to hide from people whether it was through work or through drinking, and was aware of her drinking problem. She also presented with anxiety, excessive exercising and healthy eating, and denial of drinking in excess.
The client, Ms Iris, is a 38 years old female. She lives in the urban area of a non-specified capital city of Europe. She has been married for fifteen years and she used to work as a secretary. She quitted for unspecified reasons. Though her exact level of education is not given, she has succesfully finished high-school. She was attending a school, so to learn a secondary language. Both of her parents are alive, but she doesn't maintain a healthy realationship with them, especially with her father, although she tries.
Webster want to speak with me. Ms. Webster reported she wanted to know if she could get some Ativan. She states, "If I could get some of that Ativan I would only have to drink two beers a day, I can cut back." She was asked about her earlier alleged statements of suicide. At this time Ms. Webster denies suicidal ideation homicidal ideation, and symptoms of psychosis. She states, "No I'm not suicidal, I just wanted to get into detox." she appears tearful at this time. Ms. Webster reports getting out of jail this past Wednesday and drinking since she has been out of jail. Ms. Webster expressed the only times she feels she can be sober is when she is "locked up". This clinician informed Ms. Webster of the Trosa program and Freedom House who informed TACT of having a bed available for Ms. Webster, however she denied both recommendation. After offering recommendations Ms. Webster asks if she could just receive some Ativan. Nursing staff did inform me Ms. Webster has been expected to be med seeking since her arrvial, however it has been more evident throughout this
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
Giuseppe is a 14-year-10 month-old, Latino male in the 8th grade referred for counseling through AB3632 from Hollywood Senior high School under the Los Angeles Unified School District. Giuseppe’s school counselor indicates Giuseppe has difficulty controlling his anger towards peers. She also shares that Giuseppe fights with his peers leading to a suspension from school for three days due to fighting. Giuseppe’s mother reports that at home he is very oppositional especially with his father. Giuseppe’s mother has made multiple threats to call the police and have him spend time at Juvenile Hall if the behaviors persist. The counselor and mother, both report that Giuseppe has an attitude problem and frequently
Case Example A: Elaine has sued Jerry because Jerry fired her. Elaine was on the job for two months.The job offer letter that Jerry had sent her mentioned the great career opportunities at the company and stated that her annual salary would be $30,000. The company is an employment‐at‐will employer. Elaine was given no reason for the termination. After the termination, Jerry hired a man named Kramer, who had less job experience and education than Elaine, for the position. Elaine has sued to get her job back.
A client admits to alcohol dependency on a consistant and regular basis because the loss of job. The client exhibits hopelessness and depression. The client has explained they experiencing insomnia, and decreased energy to do anything. This explains their poor personal hygiene. As the clinician the safety of the client is of the utmost importance.