IDENTIFYING DATA OF THE PATIENT:

What Would You Do Next? 

37 year old African American male, single, never married, 12th grade education , unemployed.

With a primary complaint of "Not being able to sleep at night, hearing voices and seeing
things, depressed and nightmares and flash backs" 

He reports feeling anxious and depressed with worsening symptoms for last year.  He reports two prior hospitalizations during the last year for his depression.  He reports being depressed more now with decreased sleep, decreased energy, decreased concentration and loss of appetite.  He admitted to feeling hopeless and worthless. He admitted to hearing voices again about 1 week ago telling him to "go ahead and end it all because it was not worth it.”  He admitted to seeing little images walking across the room for the last week.  Stated the suicidal thoughts comes and go but he has no plans to harm self. He denies any suicidal ideation now. He denies any homicidal thoughts now.  He reportedly had some homicidal thoughts.  He stated that he thought about killing some people about 2 or 3 days ago who were driving in the middle of the road. He reported having some homicidal threats towards an old supervisor but did not act on them. He denies any homicidal thoughts towards any one now. Reports he has nightmares and flash backs every night and sleeps only 2 to 3 hours per night. Urine drug screen positive for Marijuana metabolites. He is drug seeking for Ativan.

He reports his mother and  brother both had problems with mental illness with his mother hospitalized for her condition.  He reports his brother committed suicide via gun-shot wound (GSW) when his brother was 52.

MENTAL STATUS EXAM:  Appears to be of stated age, dressed neat, clean and appropriately dressed with no psychomotor agitation or retardation.  Speech was of normal tone, rate and volume.  Presented with a depressed and anxious mood and a bright and cheerful affect.

His thought process appears goal directed with no looseness of association or flight of ideation.

His judgment and insight appear fair.  He was Oriented x3 with intact remote and recent memory.  He was able to abstract on parables and similarities and could name the last three presidents. 

DIAGNOSIS

Mood and psychosis secondary to substance abuse
PTSD
Hypertension
Problems dealing with substance abuse
Problems dealing with war issues
Victim of war
Unemployed

“What Do You Do Next? A Clinical Social Work Discussion”

www.mymsw.info

You receive an email from a client you have not seen in about two weeks. The email contents are as follows:

“I wanted to write and explain a very bad day I had today. Today I was followed to and from my sister’s house by multiple cars. They were all different in color with tinted windows. I would make turns and take different routes but it seems like at every intersection one of these cards was cars was there. I finally got behind one of them on Main street and when he turned in the McDonald's parking lot I turned in and confronted him about why he was following me. He said he had no idea what I was talking about and had it not been for there being kids and I am assuming his wife in the car I would have beat him or died trying.

I have no idea who these people are or what they want from me. I just can't seem to be left alone. All I want is to be left alone. No one following me, talking to me or asking questions of me.

Right now is my morning. I cannot fall asleep and I cannot remain asleep. I have nightmares and intrusive thoughts about getting shot down and crashing right over Baghdad. I am helpless to do anything about it. I cannot shake these thoughts from my head.

I fall asleep around 4 AM and sleeping till about 8 AM. I get about four hours of sleep a night.

The nightmares make me sweat and when I wake up my heart is racing and I can't catch my breath.  I take the medicine I'm prescribed but it doesn't help. I don't know if it's because I've developed a tolerance for it or what but, insomnia, depression, OCD, and anxiety rule my life these past few days. I just want all of this to stop and to be a normal human being again.

I wish I could go to sleep and never wake up.

I wish all this turmoil and mass would be done with and I would be at peace.

I'm cursed to live with the guilt of killing people and also the guilt of not being able to kill enough people to prevent so many injuries during the last 13 years. That's my cross to bear and it's heavy… heavier by the day

Against your advice I listed my house for sale in the moving with my sister if and when it sells if I stay here the demons will fill my days and nights and it will be the end of me.

My sister, niece and brother promised to leave me alone and let me be to myself.

On Sunday evening, I sat in the garage, door closed and ran my truck for about 10 minutes. All I managed to do was to set off my carbon monoxide detector and give myself a headache. I don't want to die, but I'm not scared of it either.

Sorry to ramble on here but it is easier for me to tell you what's going on in my head here than in person.

The nightmares, intrusive thoughts and always being on edge are killing me. To top all of this off I got a letter that Dr. Smith won't be my psychiatrist anymore. I am scared and worried about this. I'm sure the new doctor will be nice but, I had a rapport with Dr. Smith and now I have to start all over. It's a mess…a total mess. Sorry for bugging you with my issues."

 

Upon a  chart review, you find the following diagnoses:

Bipolar I Disorder, Most Recent Episode Depressed, Severe, with Psychotic Behavior. 296.54

Post-Traumatic Stress Disorder 309.81

 

The following medications prescribed are:

Remeron 30 MG

Paxil 30 MG

Seroquel 300 MG twice a day

Lisinopril 20 MG

Klonopin 2 MG twice a day

Ambien 10 MG at hour of sleep.

What do you do next?

HELP NEEDED!

“What Do You Do Next?  A Clinical Social Work Discussion”

 

I am looking to start a conversation on real clinical issues!

I need your help and participation.

I am going to start posting a clinical situation on my Blog every Friday at

http://clinicalsupervisionmsw.blogspot.com

It can also be reached from the HOMEPAGE of

http://WWW. MYMSW.INFO

I need your Responses and Comments…

I need your participation…

I need you experience and expertise…

Step 1:  Read the Clinical Scenario

Step 2: Post your response in the comments to the blog so we can all share and read them.
Step 3: Sign them with your FIRST NAME and EXPERTISE LEVEL:
            For example: Sara, MSW Candidate or Mark, LMSW, etc.

Let’s have some fun and learn at the same time!

As a close friend of mine often says, “It is amazing what can be accomplished if no one cares who gets the credit!” – Stephen M, LPC

Kindest Regards,

Harvey Norris, LCSW
Proprietor of     www.MYMSW.INFO