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Critical analysis of patient assessment
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The patient is a 42 year old male who presented to the ED voluntarily, per ED report stating that he wants to harm himself and that he is better off dead. He also reports e should party, kill himself and wants to do this now. The patient was recently seen and discharge on 2/28/18 and went to jail after discharge. 2/28/18 the patient arrived to the ED after an altercation occurred at the homeless Shelter where he he was staying. He reported that he wanted to kill a female friend and stated that if RH didn't cooperate with him that he would walk out in front of a car.
During the time of evaluation the patient appeared guarded. He reports recently being released from jail this past Friday. He reported while in jail he was suicidal and the jail
Symptoms/Focus: Dr. Andrew Bourgeois at Simi Valley Emergency Room requested an evaluation of client by the Crisis Team for Suicidal Ideation and Grave Disability. Client placed a call to EMS on his own behalf on the evening of 05/14/2017. Client requested to be picked up from in front of a restaurant and taken to Simi Valley Emergency Room due to suicidal ideation with a plan to "cut head with a saw". Client stated to Dr. Bourgeois that his depression had increased over the last 3 days. Client denied drug or alcohol use, but was positive for amphetamine in the hospital toxicology screen. Client had been seen at Simi Valley ER and
(Effective until April 1, 2018.) At the expiration of the fourteen-day period of intensive treatment, a person may be committed for further treatment pursuant to RCW71.05.320 if: (1) Such person after having been taken into custody for evaluation and treatment has threatened, attempted, or inflicted: (a) Physical harm upon the person of another or himself or herself, or substantial damage upon the property of another, and (b) as a result of mental disorder presents a likelihood of serious harm; or (2) Such person was taken into custody as a result of conduct in which he or she attempted or inflicted physical harm upon the person of another or himself or herself, or substantial damage upon the property of others, and continues to present, as a result of mental disorder, a likelihood of serious harm;
The patient, LL, is a twenty four year old female who was diagnosed with obsessive-compulsive disorder five years ago. Around the ago of eighteen, LL started to experience many symptoms of obsessive-compulsive disorder. She had just started her freshman year at a local college and moved into the dorms with a random roommate. LL was constantly washing her hands and grossed out by the germs, so she came to realize she had a phobia of germs. She would begin sweating and having major anxiety when people went to shake her hand or her roommate would touch her food or any of her things. LL started skipping class and isolating herself in her room in order to avoid contact with other people. When her grades dramatically declined,
Mr. Farley is a 52 year old veteran who presented to the ED with a BAC of .42 and requesting detox treatment. Mr. Farley denies suicidal ideation, homicidal ideation, and symptoms of psychosis to ED staff. However, after initially denying suicidal ideation, upon discharge and sobering up from several hours in the ED and being given fluids, nursing staff informed patient he was up for discharge, at which point he asked for Ativan to help with his withdrawal symptoms. He was informed he would not be prescribed this medication and reasons why, he then expressed he could not be discharged because he was now a threat to harm himself. It should be noted Mr. Farley was seen 2 weeks ago and upon discharge reported the same. He expressed he was homelessness
Roger is at the Sage County Jail after being arrested the previous night for a minor offense. This has become a problem throughout the past Roger has been several times before. Roger has a past history of involving involuntary commitment on mental health issues. He told the jail staff that he commits crime to get sent to jail for a warm place to sleep, for a meal, and to get his meds. He is homeless and has no medical insurance or regular health care provider. Roger occasionally gets into fights with other jail inmates, has threatened suicide, and yells at the custody staff. Because of the minor nature of the crime, Roger will likely be released in 24 hours. Rogers meds are very expensive for the jail officials it costs the jail $200 per day to house Roger. So
The physician will question the patient about any stressors she may be contending with at home or work prior to her entering the hospital. The physician will order lab tests and speak with the patient to understand the psychological factors; a referral will be made for making a final diagnosis. After the physician reviews both lab tests and the psychological factors, a referral will be made for the patient to see a clinician. The referral will focus on obtaining support and stabilization. The clinical assessment will gather information using written forms as a first step, including releases to speak with family members. The second step would be to invite the family along with the client in an effort to obtain a better understanding of existing medical conditions along with any past mental disorders. Abuse as a child or abuse as an adult will be determined. The clinician will evaluate if the client is portraying any signs due to alcoholism or a drug addictions. An example of one question her clin...
The patient is a 25 year old female who presented to the ED Voluntarily for allegedly being held hostage in a basement of a house and physically and sexually assaulted. TTS assessed the patient on 2/11/18. TTS documented the patient was capable of signing voluntary admission. The patient denied suicidal ideation, homicidal ideation, and symptoms of psychosis. TTS reported the patient does not meet inpatient criteria or Involuntary commitment criteria, however Jason Berry, NP recommended the patient be observed overnight and evaluated by psychiatry in the morning. Ford Warrick, LPC, notified Dr. Osborne and nursing staff at Randolph Hospital ED of recommendation. TA staff was contacted by Maddie, Charge nurse, around 6pm who informed me that
Per mental health records (2016), the claimant had a significant history of mental illness, including depression and anxiety. Additionally, he had a history of drug, alcohol, and tobacco abuse. He received inpatient psychiatric treatment multiple times, mostly because of suicidal ideation with plan and intent. He also received ongoing outpatient treatment.
The patient is a 52 year old female who presented to the ED via LEO following an incident in which she made multiple lacerations to her arms with a knife following an argument with her boyfriend. Patient reports family conflict and relational conflict as the primary stressors contributing to her current distress. Patient reports depressive symptoms as anhedonia, worthlessness, tearfulness, hopelessness, irritability, and fatigue. Patient endorses suicidal ideation with a plan to cut her self and bleed out in her tub. The patient denies homicidal ideation, and symptoms of psychosis. Patient does not appear to be exhibiting signs of agitation, aggression, or responding to internal stimuli.
The patient is a 24 year old female who presented to the ED via LEO after an altercation with her fiance. The patient reports suicidal and homicidal ideations. The patient denies symptoms of psychosis. The patient reports that she has a vague memory her reason for being in the ER.
Mr. Zerweck is a 19 year old female who presented to the ED via LEO after being found wandering in the streets and attempting to climbing a tree. According to LEO she was found talking to her self and praying, appeared to be reaching for things that were not present, and agitated. Ms. Zerweck denies suicidal ideation, homicidal ideation, and symptoms of psychosis. Before the assessment it appeared had been under the influence of some substance. However, while Ms. Zerweck was being treated medically her father called nursing staff informing staff Ms. Zerweck made a suicidal statement while on the phone. He reported his daughter informed him when she was released she was going to jump off a bridge and if hospital staff asked her if she was suicidal
Amy is a medical administrative assistant (MAA) at B&SC Internal Medicine. She received a call from a 55-year-old patient requesting an immediate appointment because he was having an ongoing migraine due to uncontrolled hypertensor (high blood pressure). The pain became so bad he became lethargic, fell, and got a contusion on his head. The fall prompted a seizure. Amy sent a note to the triage nurse via the EMR messaging center. Amy’s note said, "Mr. X requested an immediate appointment due to an uncontrolled migraine and hypertensor (low blood pressure)."
Patient is a 45 year old male who presented to the ED with suicidal ideations with a plan to stab self with with his ninja sword. Patient also endorses homicidal ideations with a plan to "disembowel" his boss and people in New York that have treatment him poorly, with his ninja sword. He expresses feelings of anger, irritability, tearfulness, sadness, and worthlessness. Patient reports people continuously speaking negative towards him his whole life as heavily contributing factor to his depression. The patient reports a history of emotions abuse from his mother and bullying from others throughout his life. He denies symptoms of psychosis and does not appear to be responding to any internal stimuli.
The patient is a 14 year old female who presented to the ED under IVC with suicidal thoughts and plan. The patient endorses auditory hallucinations. The patient denies homicidal ideations and visual hallucinations. The patient reports depressive symptoms as: anger, isolation, sadness, worthlessness, insomnia, fatigue, and hopelessness.
The patient is a 29 year old male who presented to ED with suicidal ideation. Patient expressed relational issues, substance dependence, and non compliance with medication. At the time of the assessment the patient acknowledges having current suicidal ideation with multiple plans. He states, "My current thought is suicide by cop." He reports homicidal ideation, whoever will not give specific individual do to him not wanting to incriminate himself. He states homicidal thoughts are towards anyone who owe him money or has do him wrong in the past. He relational issues are directed towards the mother of his child. He describes depressive symptoms as feelings of sadness, irritability, isolation, and loss in usual pleasures.