Substance Abuse Case Study Sample
. IDENTIFYING DATA: The patient is a 29 year old AA male currently serving 25 year setence for COCAINE-SALE/MANUF/DELIV (X6) COCAINES POSSESSIONN (X6) GUN/W/DEADLY/WPN (x3). He entered FLDOC 4/7/2010 TRD:10/03/2033. This is his first prison term in the state of Florida. II. REASON FOR ADMISSION: Transferring SYSM: The patient referred to MHTF due He presented of three episode of self-injury behavior within 2 Weeks. IM has been in and out SHOS for cutting self and have had the extraction the team. III. RELEVANT MEDICAL AND MENTAL HEALTH HISTORY: Per records, . Medical Hx: see inpatient chart. Substance Abuse Hx: Per record review COCAINE possession. No history of substance abuse treatment. Per OBIS IM has not been identified as a mandatory participate in substance abuse treatment. Past psychiatric Hx: Records indicate that the patient has had a history of first outpatient at the age of 8, and has been Baked Act many times for suicidal attemptst. Hx of MH Tx in DOC: During this incarceration IM has received inpatient and outpatient treatment for self-harm, depression, and suicidal threats. He has an extensive history of inpatient admissions including MHTF. IV. ADMISSION MENTAL STATUS EXAMINATION & PROVISIONAL ADMISSION DIAGNOSIS: DSM-5: The patient has been diagnosed with (F32.0) Unspecified Depreesive D/O , …show more content…
CURRENT MENTAL STATUS EXAM: The patient was evaluated on 7/11/17 by MHP. On that day, the patient is O X 3 (oriented times three; oriented to person, place, and time). His thinking is clear and linear. Memory appears adequate. Affect/mood is somewhat congruent, he wore standard prison attire, eye contact and hygiene were appropriate, and he was cooperative with the interview. His speech was typical in rate, tone, and clear. Thought process was coherent, no difficulty with attention or concentration. He denied suicidal and homicidal ideation with no intent or plan. He reports eating 3/3 of the meals & achieving 7-8 hours of sleep per
Co-Occurring Disorders Case Study
1125 Words | 5 PagesCo-occurring disorders are common with most client cases that are presenting with a substance use disorder. Rosa is presenting with a history of several suicide attempts, alcohol use disorder, Post traumatic Stress Disorder (PTSD), and Borderline Personality Disorder (BPD). The client’s most severe symptoms are anger, fear, and shame. It is these symptoms that are complicating her life, causing distress, and self harming behaviors. Additionally, her treatment history is limited since she does not finish her therapy sessions.
Case Study Raewkon
234 Words | 1 PagesRaewkon is a 16 year old male who is before the court on the above charges. He has been before this court multiple times; however, he was only on probation for a trespassing charge from March 30, 2014 to September 10, 2014. It has been reported that Raewkon was recently admitted at Maryview Behavioral Health care for a three day evaluation. He had several psychological evaluations conducted and has been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), Mood Disorder, Conduct Disorder, and Impulsive Disorder. He is currently prescribed Vyvance (20 mg)
Daymark Presentation Case Study
272 Words | 2 PagesMrs. 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.
Harm Reduction Case Study
192 Words | 1 PagesR: Client presented well groomed and calm. His mood was euthymic, and his affect was within normal limits. Client’s thought processing was goal directed and coherent while being instructed on LAMP VASH referral. Client reported being worried about meeting his VA claim appeal dateline.
Tower 31 A-Buckeye Jail: Case Study
53 Words | 1 PagesOn 07/16/2016, at about 1830 hours, in Tower 31 A-pod located at the Lower Buckeye Jail, 3250 W. Lower Buckeye Rd. Phoenix, AZ 85009, Inmate Burgess, Randall T286059 was transported via ambulance to Maricopa Integrated Health Systems (MIHS) per Dr. Gregorio, Gerardo CH117 due to Heart Disease, alcohol withdrawal, and risk for
Psy 270 Week 6 General Hospital Data Analysis
595 Words | 3 PagesThe mental health status of a patient is very important when you are dealing with drug abuse and suicidality. Knowing if there is co-morbidity in the diagnosis will help determine the best treatment plan for the patient. However, not all hospitals are required to run mental health screening on their patients. Often this test is left up to the desecration of the medical staff on duty at the time of the patients intake. Data Analysis Plan
Case Interview Detainee Hargrow
645 Words | 3 PagesPrior to the interview, I was informed by Supt. Walsh that detainee Hargrow had just received another disciplinary infraction. I interviewed detainee Hargrow on wing 1A privately. I questioned Hargrow if he was on any medication and he said “Haldol and Klonopin, but did not know his diagnosis’s.
Ms. Morgan's Case Report
725 Words | 3 PagesShe said she thinks she was on drugs at the time. Ms. Morgan has a valid case with the agency dated 7/18/2015 for Dependency. Ms. Morgan is diagnosed with Bipolar and Schizophrenia. Ms. Morgan is not taking medication at this time and she is not receiving mental health care. Ms. Morgan is supposed to receive care through Central City Mental Health Clinic, but missed her appointment and never rescheduled.
Jadine Sawyer Mental Status Examination
71 Words | 1 PagesA Mental Status Examination (MSE) was completed on Jadine Sawyer to evaluate her level of thinking. This examination was conducted to document how she is feeling with the life changes that are taking place in her life. Jadine’s level of thinking was recorded to provide a diagnoisis to the symptoms she is experiencing. This Mental Status Examination (MSE) also was formulated to provide a treatment plan to better assist the client.
Omhc Case Study
485 Words | 2 PagesPt has history of drug abuse and numerous admission to substance abuse program for heroine and crack/cocaine abuse. She was able to maintain abstinence for certain period of times only during incarceration. Pt has recently arrested after fighting with a woman, whom pt perceived as threatening. Pt was arrested since pt's attack led to the other woman's injury. Pt is currently on probation for 4 1/2 years for second degree assault and theft.
Intake Appointment Summary
199 Words | 1 PagesD: Client was on time for intake appointment. Together, discussed the assessment recommendation and barriers to successful treatment outcomes. Client reviewed and signed of all treatment admission paperwork, including treatment agreement, ROIs, THS treatment policies, THS alcohol drug Services patient rights, THS patient responsibilities, THS health and safety information, THS counselor disclosure information, patient grievance procedures, THS HIV/AIDS information, THS notice of privacy practices, referral to Quit smoking, and marijuana policy. Treatment plan was developed, which was focused on Dim 4, 5, and 6; focusing on developing readiness to change, identifying relapse potential, and building a strong family and social support system.
Confidentiality Assessment
1334 Words | 6 PagesMs. Lewis was referred by Maricopa county correctional health services to receive an evaluation for potential to transfer to the mental health unit. She was serving a 10-year sentence for manufacturing and possession of illegal substances. She had served 1-year of her sentence and reported symptoms of anxiety, obsessive rumination, and sleep disturbances. Notification of Purpose and Limits of Confidentiality Upon arriving for her appointment, the Informed Consent and confidentiality agreement was discussed both verbally and in writing with Ms. Lewis. The purpose of evaluation was reviewed along with mandated reporting laws and danger to self (DTS) and danger to others (DTO).
Assisted Suicide Case Summary
290 Words | 2 PagesThe patient is a 53 year old male who presented to the ED via EMS intoxicated and reporting suicidal thoughts. The patient denies homicidal ideations and symptoms of psychosis. The patient endorses depressive symptoms including: tearfulness, isolation, and insomnia. During the time of the assessment the patient is awake, alert, cooperative, and clam. the patient reports that he had been drinking to 2 pints of alcohol earlier during the day.
Robbie J: A 19-Year-Old Single Caucasian Male
757 Words | 4 PagesBasic Information Robbie J, a 19-year-old single Caucasian male. His income and community description is not applicable. He is living with his parents, and is a first-year college student. He has been referred because he has started drinking again and lack motivation. He is currently in family counseling with a social worker on the rehabilitation team.
Social Work Case Study: Substance Abuse
967 Words | 4 PagesClient informs staff that she does not have a history of drug usage in the past aside from alcohol consumption. Client states that there is no history of substance abuse in his family except her father use of alcohol. Client started using crack around age 28 because she was feeling more depressed and did not have a way to control her depression about from this
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