Comprehensive Mental Health Assessment II
Derek W. Booth
Indiana University Purdue University Indianapolis
I: Identifying Data.
Ashley K. is a 23-year old white female who was admitted to Warner Transitional Services on 11/21/12. II: Chief Complaint.
“ I am a little anxious and upset right now. IDTC in Lafayette could not do anything for me”. III: Informants.
Assessment information was provided by patient. Interview was conducted in a private room along with psychiatrist, and lead clinician. Other sources used for this evaluation included documents from her previous two placements.
IV: Reason for Consultation.
Client was referred to Warner Transitional Services by Indiana Developmental Training Center of Lafayette. She became a candidate for Warner’s program due to her progression through treatment, improved behaviors, and being able to function at a higher level than most patients at her previous placement. Patient was discharged from state hospital and transferred to facility. Patient will most likely remain at Warner until she can be transitioned into a group home. The treatment team believes that Warner’s program can improve her overall functioning. The team also believes that she can benefit from a more group orientated, and less restrictive environment. V: History of Present Illness.
The information obtained in the assessment, and previous records leads me to assume the patient has had a very complex history. Documents obtained paint Ashley as being known for manipulation, and making up stories. During the interview she was often vivid and graphic when she began to describe details. Also, as she told her story redirection was often needed to stay focused on the question discussed. She tends to want to answer questions with questions, and seemed to prefer elaborating on certain topics, rather than progress and complete the interview. Ashley was forthcoming with information stating “ I usually mess up by hurting myself when I talk, or hear from my family”. She then rolled up her shirt and showed me a bunch of superficial cuts on her right arm. Patient seems to be a good story teller, but a poor historian. During the assessment process the treatment team was somewhat confused as to if some of the historical details provided were derived from Ashley herself, previous documents, or family members. VI: Psychiatric History.
Ashley has historical diagnoses of PTSD and major depression, made at the age of seven. St. Joseph County DCS became involved with her in 1999 due to substantiated physical abuse by her father. The very next year she was seen in the emergency room for a 25 pound weight loss sustained in one month. At this time Ashley reported sexual abuse by her father. The patient’s father previously had been investigated for molesting a neighbor’s child. As a result, the patient and her siblings were removed from the home, and made wards of the state. At some point they were returned to the home then Ashley’s sisters made allegations that she had been “humping” them. In 2004 Ashley was once again declared a Child In Need Of Services. Since then, patient behavior has been difficult to manage. She has a documented history of defiance, property destruction, aggression, and self-harm. As a result, Ashley has had multiple psychiatric hospitalizations in various locations throughout the state of Indiana. VII: Medical History.
Patient has no known drug allergies, no surgical history, and achieved developmental milestones on time. Patient currently suffers from hypertension, GERD, and obesity. She is prescribed Toprol XL 25mg for HTN, and Zantac 150mg for GERD management. Upon admission she was given a TB skin test, ordered a CBC with diff, CMP, and TSH. All results were unremarkable. Patient is scheduled to have vision testing, and her wisdom teeth removed bilaterally sometime in December 2012. VIII: Social History and Premorbid Personality.
As mentioned above the patient experienced...
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