DSM Diagnosis: Include behaviors & symptoms consistent with diagnosis. 296.33 Major Depressive Disorder, severe; deferred; chronic pain; family and social Background information: John Smith is a white male in his mid-fifties residing alone in an apt complex. Pt has an ongoing struggle with depression for many years. Pt was admitted voluntary to SBBH for having hallucinations. John reported, he has received therapeutic treatment in the past for his depression and hallucinations. Pt source of income is SSI Disability. He does not have any legal matters. John strengths consist of verbal, motivated for treatment, and use health care systems. His weaknesses are depression, poor health, and sleep disturbances. His barriers to treatment are hallucinations and being …show more content…
I explained to the patient that I am an intern student. I would be sitting in on session from time to time. The patient was cooperative when speaking and engaging with the intern. The student started with small talk and asked the patient his thoughts and feelings. Intern asked, “what is your current living situation?” Pt reported, “I live alone in an apt complex. I am considering a nursing home placement. My daughter is helping me with my placement.” The intern asked, “are you seeing things that others are not?” Pt reported, “not today.” Also, the intern asked, “are you hearing things that others are not?” Pt said, “no.” The intern asked, “what do you want happen while you are at SBBH?” Pt stated, “I want to be able to figure out what is going on with me. I can’t keep living like this. Something has got to live. I was discharge yesterday and I had to come back. I don’t understand what is going on.” At the end of the interview, the student answered the patient questions. Pt presented in a euphoric mood during the interview. He appeared to be guarded and reserved when talking to the intern. Pt was cooperative when answering the
Ms. Alexandra Estrada is a 45 years old Hispanic female. She arrived at BHWS from HELP USA on 11/20/2013. She is currently living in the Department of Homeless Services System since 12/25/2012. Ms. Estrada stands 4”10’ inches tall and weighs approximately 100 lbs. She is of olive skinned complexion, has bleached dyed blond short hair, and has distinct scars on her forehead and left arm.
Mrs. Jones is a 67 year old female who presented to the ED via LEO under IVC through DayMark Recovery Services. Per documentation Mrs. Jones has been non compliant with medications and has been experiencing symptoms of psychosis. At the time of the assessment Mrs. Jones appears calm and cooperative. She does present with tangential speech and vaguely answers questions. She recently was discharged from Novant health 1/3/17 and followed up with DayMark 1/11/17 with new changes in medications.
Ms. Conley is a sixty-two-year old African American female with a history of Schizophrenia. She was referred for Mental Health Skilling Services by the case manager at Tuckers Psychiatric Hospital after she had been hospitalized for twenty-two days at the hospital due to her acute psychotic symptoms. Prior to Ms. Conley’s most recent hospitalization she was living independently in her own home where she was struggling with being able to recognize personal danger as evidenced by her placing unsafe items in the electric shock (at least once a month); noncompliance of medication treatment (daily); delusions that individuals are plotting against her (daily) which results in her acting out in an aggression manner; and spending a disproportionate amount
Pt is 43 years old AA female who decided to return to OMHC after the program that she attended, Universal Counseling, was closed down. Initial admission to OMHC was around 2012. Pt has been diagnosed with PTSD, Bipolar, and Anxiety Disorder in the past. Her depressive episodes started at the age of 13 and after she was sexually assaulted by distant uncle. She later developed aggressive behavior around late teen and was involved in numerous arrests, starting the age of 18.
Jessica Stemp is a 27-year-old female army veteran with no pertinent past medical history presents with insomnia and irritability. Jessica, an administrator assistant at the chaplain services at Veteran Affairs was urged to come in by her employer or boss following a verbal and physical altercation two days ago with a client who wanted to reschedule an appointment with her boss - This event happen in light of her potentially being laid off because of her performance at work as well as her tardiness. She doesn’t remember the progression of the encounter however, she just remembers shoving the client. She describes how this never happen before.
At this time the client presented with a readiness to change and is highly motivated to receive treatment at MRFH. The client was diagnosed with Alcohol Use Disorder: Severe, and Cocaine Use Disorder: Severe. The client stated, "I am pretty much homeless and I left the Salvation Army after I was about to get into the Step Up Program. There were so many drugs at the Salvation Army. I want to learn more about myself and my addiction.
She was very warm and eager to teach me all about her craft. I learned a lot in the two days I worked with her. There was never a dull moment and I got to see so many different patients; patients of different backgrounds, ethnicities, age groups, and gender. All my initial fear was basically fear of what I was getting myself into.
Talk about what went well in the scenario. I perform vitals sings and communicated effectively with Mr. Ahmed. I educated the patient in areas such as dehydration, fall risks, intake and ouptup measurements. In addition, I administer oral and intravenous medication to ensure proper drug
The social worker must work very closely with their client and the clients support system to develop a case management plan that will set the client up with the highest likelihood of success. In the case of John Smith, after much consideration, he is best suited to maintain a healthier lifestyle, become engaged with Cognitive Behavioral Therapy, join the UNBC gaming club, and to maintain his psychotropic medication regime. If John works to balance and achieve all of these goals, he will be able to manage his symptoms of schizophrenia then best and be able to live a productive and happy life, while coping with the restraints of his mental
Nurse Practitioner Interview I spoke with a friend’s sister, a recent graduate DNP, who works as a women’s health NP at a public health clinic system in Utah. Role The role of the women’s health care nurse practitioner can vary widely depending on the setting. J. Yale sees patients for both annual visits as their main care provider and for gynecological issues (personal communication, September 9, 2016). “Many people don’t realize you can do annual visits,” she said, “for example, I can treat someone for high blood pressure in the clinic, in an office setting.”
Saloojee, and this patient was to be discussed. Stephanie gave an update on the patient and gave me a lot of credit for ordering new tests to confirm our suspicion of factitious diarrhea. I really felt welcomed and appreciated for the week to come. Other concerning things on the differential were motility issues, even though she had gastric motility testing come back normal, and colonoscopy with biopsy, despite being previously negative. Now, it could have been an issue with dysmotility in the small bowel, but there are no good tests for that, so the team ordered a capsule-endoscopy to check the entire length of her alimentary canal and measure the time it took from mouth-to-anus, which would clue us in on motility issues.
I was glad, however, that my instructor allowed us to pair up that day with our patients that way we could learn from each other. I enjoyed talking with my patient, and hearing about his military service, and his family.
WHICH DSM DIAGNOSIS DOES THE CLIENT HAVE I speculate that I would diagnose Sam with a personality disorder, specifically the Schizotypal Personality Disorder. Schizotypal personality disorder is defined in the DSM 5 as a pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour, beginning by adulthood and present in a variety of contexts. Sam has met the following criteria of the schizotypal personality disorder: Significant Impairments in personality functioning which manifest by: a. Identity: Confused boundaries between self and others; distorted self-concept; emotional expression often not congruent with context or internal experience. The case states that Sam has always been an odd child and that his behaviour around people especially those that are outside of his
Smith informed staff the reason of herself referral for service is due to her rape incident when she hooked up with a guy she met at the bar where she was going to buy crack. Another reason Client is seeking for service is due to her daughter safety and protecting her daughter from the child’s father. Client report that she began drinking several times a week around the age of 13. She stated she started drinking heavily, when she felt depressed and that is an everyday situation. Jessica drinking became progressively worse over the years and she did not notice it was a problem until after she began using crack.
REFLECTION OF THE INTERVIEW 2.1 Description A component of the Effective Communication module, is an Inter-professional Education (IPE) enrichment activity and we were put into groups with the Pharmacy students. There were in total 2 Nursing students and 3 Pharmacy students. We were tasked to interview a healthcare professional. We interviewed Dr Edwin Lim from Tzu Chi Free Health Screening and Free Clinic (TCFC). He specialises in Family Medicine.