Mental Health Examination - Case Study Example

Mental Health Examination Report Background Information Patient is 77 years old, diagnosed with schizophrenia, paranoia. Axis I: Delusional disorder. Axis II: Deferred. Axis III: (1.) mitral valve prolapse and repair. (2.) left breast malignancy, status post mastectomy. Axis IV: (1) relationship issues. (2) non-compliance with medication. Axis V: GAF= 25 on admission, 45 on discharge GAF score 15. Since Hospitalization, the patient has not any particularly acute psychiatric episodes , the patient is prone to bouts of depression and often refuses to take medication. Patient has insomnia, weight loss, heart palpitations, back pain, depression and hallucinations. The patient herself does not have an extensive prior hospitalization history. She does have history of: depression, hypertension, diabetes. Treatment recommendations are: management per psychiatry. She does not have any prior history of mental illness or a family history of mental illness. She is a retired school teacher, and worked for nearly 40 years before retiring. There is nothing in her professional record to indicate any psychiatric problems. Though she does claim that she has been depressed all her life, Interviews with family members indicate a person who is generally lived a balanced life . Though she and her husband never had any children and had only each other for company, they seemed generally to be a normal old couple. Financially, while they were not very well off, They seemed generally comfortable. She says she is in the hospital because she is losing weight and is overwhelmed with things at home. Her husband died while both of them where in the hospital , he was sick for a very long time with cancer in his lungs and he never went to the doctor because they had no insurance and no money for doctor visits. She went in because she was dehydrated and getting sick. She feels now that her husband is gone that once she gets back home that she is going to be overwhelmed and have no idea how to take care of the herself, the house and bills. Her family said she seemed fine before her husband died, and now she has seem to gone crazy. it must be the way she is dealing with his death because she did not get to attend his funeral since she was admitted to the psych floor in the hospital and did not seem stable enough to attend without possibly presenting an outbreak during the service Mental Status Examination The interview was very normal. She cried once during the interview when she talked about her husband. She was very co-operative and seemed depressed and anxious. She stated her plan to recover and gain strength while in the hospital.. No history of drug or alcohol use. She did state that she has had had depression all my life. She did state that she has no children and only older siblings to help her. She did say that most of them only want to put her into a an old age home and take her money because she is wealthy. She is retired and lives at home. She talked about how she thinks she will have a guardian angel soon to help her once she gets to go home. Most of her statements were made in a normal tone of voice, neither unduly soft or unduly loud. Indeed if it were not the setting of a psychiatric ward and the lone episode of her breaking down and crying , this would have appeared as a normal conversation to any outside observer. The emotional state of the patient seemed to be constantly changing, from an extreme sense of optimism to pessimism. She sometimes would talk of her husband in present tense and finally overwhelmed with grief as she talked about him dying. She was particularly angry that she was not allowed to go to his funeral. While she did go over many thoughts and emotions, there was a high degree of coherence in her thoughts and words and she did have the ability to lay out her thoughts in a linear manner without being too distracted and moving to another thought without completing one. She never mentioned her hallucinations, or any schizophrenic episodes. She is oriented to time, place and person. She does know where she is, why she is here, to a degree. Her memory is fairly accurate and she remember most of the things in the short term including the death of the her husband and her recall of most significant events in her life are fairly accurate. Her ability to think intellectually has also not been compromised. She taught Mathematics in high school, and some brief sojourns in her academic area revealed a fairly reasonable level of grasp of her intellectual side. She was comfortable talking about abstract things as in spirituality. She is a deeply religious person and a regular church goer, and she briefly talked about her husband being finally free of pain and that she knew that he was in a much better place waiting for her. She does understand , though not completely that why she is where she is , though she is overwhelmed at times with the enormity of her loss. Summary When evaluating various events in life in the order of how much stress is caused by them to a person, the event right on the top is the death of a spouse. In this case this was a marriage of 55 years. The patient has had no children, and her only companion is no more with her. There are other factors which make this even more difficult for her. Her husband handled most of the household decisions and finances, and there is no sense of continuity in those areas, because it did seem that her husband did not prepare her for a time when he would not be there. She does have a close relationship with her siblings, but all of them are older to her. The children of the siblings do seem to care for her but there is a strong consensus that she move into a nursing home. Though a reasonable suggestion, she sees it as a conspiracy to get her money. That may or may not be true, but she believes it is. She does have a decent amount of savings from a life very frugally lived.( including not going to Hospitals , or even having any substantial luxuries). Having said this there are serious physiological and psychiatric problems. She does have cardiac and diabetic problems apart from possible malignancy in her breast. Her hallucinations have been documented as well as episodes of Schizophrenia. Psychiatric care with intensive counseling is strongly recommended. Read More