Family: Dionisio is a 17 year old Hispanic male who resides in Clark, NJ with his mother, Sonnia Estremera. When CM first received Dionisio’s case Mrs. Estremera reported that youth has difficulties following household rules. She reports that Dionisio needs reminders to complete basic household chores such as throwing out thrash. It was evident that there was a breakdown in communication between Dionisio and his mother. Since Dionisio has been attending family therapy at Trinitas Child and Adolescent Outpatient Department there has been in improvement in youth and his mother relationship. Due to Dionisio non-complaint behavior at Trinitas Child and Adolescent Outpatient Department he was recommended to attend IOP at High Focus Centers in Cranford. Dionisio and his mother continues to address their family challenges in family therapy at the High Focus Center in Cranford. It appears that both Dionisio and Mrs. Estremera are both invested in family therapy. Mrs. Estremera also reports that Dionisio behavior in the home has improved and she is proud of the progress that he has been making so far.
Additionally, she has formal supports; in-home therapy, and DCF. Rosemary does not identify with a particular culture or religious practices, however she has her own set of beliefs that consists of self-reliance, putting her children’ s needs first and working hard, however this has not always been the case. The family became involved with the Department due to marijuana use during her pregnancy with James and subsequently, after six months of working with the Department, her children were removed due to multiple reports of abuse and neglect and a supported allegation of physical abuse of Jeremy by the youngest children’s father and domestic violence. Over the past year Rosemary has worked diligently to have her children returned to her care and custody.
She has never worked in one job for more than a few years and has spent much of her adult life as a student”. 6. Feelings of hopelessness: It is described that Ellen began Psychotherapy after it became clear to her that her boyfriend of 4 years had no plans on marrying her and her depression significantly increased. The specifiers of Atypical Features, Severe and Early onset were all included as Ellen describes the atypical features of mood reactivity, hypersomnia, leaden paralysis and a long standing pattern of interpersonal rejection sensitivity.
Dr. Keith requested a mental health evaluation on a Mr. Alewine. He is a 28 year old male who presented to the ED via EMS for chest pains, suicidal ideation, and symptoms of psychosis. Mr. Alewine reported arriving in Siler City from Tennessee after a 16 hour bus trip. He reports after his 16 hour trip, he went to a mechanic shop to call 911 for chest pain and suicidal ideation without a plan after stressing about having a place to stake for a few days. Per documentation Mr. Alewine was asked about current chest pain on a scale of 1 to 10, he reports a 1. At the time of the assessment Mr. Alewine endorse suicidal ideation with a plan to overdose on his medications and experiencing auditory and visual hallucinations. He reports seeing demons
Paula is a 43-year-old HIV-positive Latina lady initially from Colombia. Aside from confronting the disgrace of her HIV status and a bipolar issue, she is a divorced person who loses custody of her child’s (Plummer, Makris, Brocksen, 2014). She is accordingly inclined to psychological and emotional distress (Plummer et al., 2014). The Physician who is treating Paula with her may physical ailment ended up baffled with her because she utilizing all-encompassing medication instead endorsed prescription (Plummer et al., 2014).
Treatment Plan of Ms. Smith Micah Sparks Grand Canyon University Treatment Plan Case History for Treatment Plan Psychological Evaluation Name: Sally Smith SS#: 000-00-0000 DOB/Age: 6/10/1972 42-years-old Date of Examination: 11/26/2016 Examiners: Fred Looney, PhD Chief Complaint: Mental Sources of Information: Clinical Interview with Sally Smith Medical Records Brief Mental Status Examination Wechsler Adult Intelligence Scale-IV (WAIS-IV) Background Information: Ms. Smith is a 42-year-old African American female born November 10, 1972. She currently lives in with her mother.
Karta’s daycare called DCPS on Karta’s mother Michelle. The daycare reported that Karta looks disheveled when she comes to school and her eating habits had increased as if she wasn’t eating enough at home. DCPS conducted an investigation and removed Karta her from the mother’s custody for neglect and parental substance abuse. Michelle substance of choice was alcohol. DCPS tried to find out if Karta had any relatives to stay with, but her mother was not cooperative with providing the information.
The patient is a 52 year old female who presented to the ED via EMS with bizarre behaviors. Per documentation neighbors found the patient screaming in her house. Per documentation LEO found the patient attempting to drink a closed bottle of alcohol hand sanitizer fluid. Patient presents with disorganized thoughts and irrelevant subject matter when asked questions about behavior upon arrival. Nursing staff was asked about status before the assessment and reports improvements in the patient bizarre behavior.
Substance/medication-induced depressive disorder appears to be related to Mrs. Smith mood disturbance; it has been used for many years as a coping mechanism. Based on the medications that Mrs. Smith has taken prior, this diagnosis best fits her symptoms and treatments. The secondary differential diagnosis is acute stress disorder acute stress disorder is caused by a traumatic event that has occurred in an individual’s life. Mrs. Smith has endured traumatic events in her life and these events occurred when she was a child. Child-abuse, self-mutilating and then eventually substance abuse is what brought me to this
Catherine Gibbs is a 25-year old female who functions within the Mild range of Intellectual Disability. She has a diagnosis of Intermittent Explosive Disorder, and Attention Deficit Hyperactivity Disorder. Catherine is verbal and ambulatory. Catherine resides in a residential home and requires 24-hour care and supervision. She has a history of challenging behaviors, which are monitored by her Residential Behavioral Plan.
On 9/28/2015client met with Dr. Shuster and she was diagnosed with: Axis 1: Post traumatic stress disorder; 309.81 (primary), symptoms regarding the traumatic event in Columbia. 2. Mild neurocognitive disorder 331.83, rule out in light of the reportedly forgetting appointment, and being unable to recall any of 3 objects, needs neurocognitive testing to rule. No medication was prescribed and in the event that the client agrees to see a therapist Dr. Shuster will issue a referral, and if client memory becomes more of an issue client should be re-assessed for safety.
medication, alcohol) or another medical condition A: As evidenced by: Client decided to seek treatment at the VA hospital. Client’s mother noted that he began to experience depression, insomnia, and flashbacks of his wartime experience 1: Supported by: “he has been very depressed ever since he returned from the war. The client reported that during his tour he killed a civilian, “for the fun of it.” 4: Supported by: “He became preoccupied with watching TV news stories about this event.” B: Supported by:” Client’s mother noted that he been very depressed ever since he returned from the war 1: Supported by: “The memory of the incident continues to haunt him, and he is racked with guilt.”
Her symptoms presented when Client A’s father started a new job and when she transferred into a new school (precipitant). Client A admits to feeling anxious, angry and frustrated when she is being ignored and misunderstood. She firmly believes everyone in her life should listen, believe and try to understand her. When others do not abide by her decisions or value her thoughts and emotions, she feels abandoned and that no one cares for her (maladaptive cognition). In response to her thoughts/emotions, Client A reacts with angry outbursts and becomes defensive, defiant and disrespectful towards others along with efforts to controlling them as well (maladaptive behavior).
He denies any perceptive abnormalities are delusional thought content, but he does demonstrate some impaired reality testing. Psychiatric Hx: Kwalon was under the care of CSB from 2010-2011 where he was already provided the diagnosis of ADHD and mood disorder with conduct problems, for which he has been prescribed a combination of Abilify and Concerta. He has a history of assaultive, aggressive and disorderly behaviors. These medications were at that time continued with sporadic compliance. After several no show appointments in 2011 his medication management was transferred back over to his PCP.