What would you do differently with this patient if you could conduct the session over?

What would you do differently with this patient if you could conduct the session over?

If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

 

 

 

 

 

 

 

 

 

 

 

CASE STUDY

 

Chief Complaint: Patient stated “ I came in because I was depressed and having suicidal thoughts.”

 

HISTORY OF PRESENT ILLNESS:

Y.R is a 18-year old African American female who came to ED due to severe depression, suicidal ideations, non compliance with medications, severe anxiety, racing thoughts, and mood swings, marijuana use, commanding auditory hallucinations, and difficulty sleeping at night. During interview patient started “I feel depressed, anxious, I have trouble sleeping at night, I stopped taking my medication in over a year because it was making me feel worse. I used to take Zoloft and ability. I hear voices telling me bad and negative things like give up and hurt myself. I have thoughts of wanting to hurt myself.” Patient denies homicidal ideations. The patient at this time is danger to self and others. The plan is to start medications, encourage patient to attend groups, and social service to follow up with placement and appointments (including PHP and drug rehab referral.)

 

PAST PSYCHIATRIC HISTORY

Patient denies and past inpatient psychiatric hospitalizations, reports seeing psychiatrist Dr. H., outpatient clinic at Howard Brown. Last visit was in May 2021. Patient in the past was prescribed Zoloft and Ability but claims that both medications made her symptoms worse and stopped taking both medications. She has been noncompliant with medications over year. Patient wishes to try different psychotropic medications. Patients received prescriptions for Abilify 2mg on 4/7/2022 as per medication reconciliation external profile but never took the medication.

 

Patient reports past suicidal attempt, twice in her lifetime, first attempt was when patient was 13 years old via biting her self in her arm and lip. She also attempted this same behavior again at 16 years old. (2ndattempt). Patient denies any past homicidal attempts.

 

Patient reports being diagnosed as major depression, ADHD, and PTSD. Patient reports being sexually abused when she was a teenager.