Ptsd Case Studies

Presenting Problem: Pt is a 15 y/o female, domiciled who recently was admitted to Dominion Hospital after overdosing on 200 pills of Tylenol and aspirin 11/29/15. Pt has also been caught drinking in school. She drinks about a half liter of liquor a day morning and night. She is currently in some honors class at Stuart High school and failing all of them. She states that biological parents were prostitutes and currently serving time in jail. She also states that she has a hx of being touched by a family member, she was vague with providing detail, but she does have related to PTSD related symptoms in regards of flashbacks and nightmares. Pt states difficulties with bullying at school as well having difficulties in social environment. She states she does have any friends, and demonstrates a difficulty for to adjust to life

Medical Hx: Congenital hearing loss that needs to be examined as well as obesity. She had hearing loss due to her overdose.

Family composition/ Current Supports: Pt is a 15 y/o Caucasian female who resides at home with her adoptive family and 3 biological siblings in Falls Church, Virginia. She is a tenth grade student at J.E.B Stuart High School in Falls Church

Pt was 4y/o at the time of adoption, her sister recently returned home from a residential program. The youngest sister is 14 and the pt has sexually abused her on three separate occasions in the last 7 years. CPS is involved and investigating allegations. The youngest sister attempted suicide and was hospitalized recently. There is biological family history identified as severe for mental trauma and distress.

Social History

She was adopted, so unknown about her birth history. She admits to marijuana and alcohol use. She endorses sexual trauma at the hands of perpetrator related to her and her family, but is vague in giving