Case Study
Your Setting
A rural hospital in a mid-sized regional town. The hospital has an emergency department, a combined ICU/HDU/CCU, a general medical ward, a general surgical ward, a rehabilitation ward, a paediatric ward and a maternity unit. On the hospital campus is a small, voluntary mental health unit which also covers drug and alcohol. There is no secure mental health unit in your town.
Your Patient
Hannah identifies as an Indigenous woman in her 30s. She is currently single with no children and lives in a share house with two roommates. She is currently working on a casual basis in retail. She has no relatives in your town and few community ties. She moved here to get away from stress in her old environment, and because a friend suggested work was easy to obtain.
Current Presentation
Hannah is bought to your emergency room in a mid-sized rural hospital by ambulance with police accompanying for an overdose of diazepam and ingestion of alcohol after an argument with her roommate.
Backgoround
On previous admissions when speaking about her history, Hannah has described a long history of involvement in the mental health system including the diagnosis of several mental disorders, the prescription of various psychiatric medications, and multiple psychiatric hospitalizations.
From her previous notes from other admissions, you can see that Hannah has stated, “I had a very traumatic childhood. There was a lot of chaos in my home, a lot of abuse.” She described her father as unstable and prone to bursts of anger. During phases of her life when her father was the primary caregiver, Hannah explained that the needs of the children were often not met creating an unpredictable and insecure environment. Hannah reported that her father had difficulty maintaining a job, often relocating the family during her early childhood years. When she was approximately 11 years old, her father stopped working altogether and her mother was employed at two or three jobs at a time to meet the family’s financial needs. During this time, Hannah and at least one of her siblings experienced incidents of physical and sexual abuse by their father. She has described being perpetually “frightened”, and she remembers feeling that the children’s basic needs were often ignored. To illustrate, Hannah recounted an event when she fell and broke a bone. Hannah explained that when she sought help for her injury, “My father just lost it. He was screaming at me and telling me how much money I was going to cost him, and I was just terrified.”
Hannah described the abuse she experienced as episodic. When discussing the impact of these experiences, she recalled that living with a perpetual sense of fear was devastating. Hannah reports that her parents divorced a few years later. When Hannah was in 9th grade, she was taken by her mother to see a general practitioner to address sleep difficulties and stomach aches. The medical record states that she was prescribed combination treatment with Imipramine and Nortriptyline at this time. Hannah indicated that she took the medications for a few months but chose to stop taking them. It is unclear if she consulted a physician before she discontinued use. Counselling was not offered as an option. It was not until later, when she viewed her medical record that she realized she was given a diagnosis of depression by this provider.
According to Hannah, at some point before age 16 she began using marijuana and alcohol. She acknowledged smoking marijuana daily and described this behaviour as an attempt to “get away” and reported she would often drink herself into oblivion. During this time, Hannah saw a general practitioner. At this appointment, the physician noticed cut marks on Hannah’s arms. The medical record indicates she was treated again for depression, with the doctor prescribing Paroxetine. It was also suggested for the first-time that she seek counselling, however, Hannah chose not to initiate these services at that time. After three months of taking Paroxetine, Hannah reports that “she didn’t like it” and discontinued the medication. The medical record indicates that it was later determined by a clinician that neither the earlier medications nor the Paroxetine were effective.
Despite two attempts to address her emotional difficulties through antidepressants, by late adolescence, Hannah’s clinical status was declining. At this point, Hannah started her first of what would be a long phase of various mental health services. Initially, Hannah attended three sessions of outpatient psychotherapy that she did not find helpful. At age 16, at ther ecommendation of her physician, Hannah participated in an intake interview with a mental health provider in which the provider reported that Hannah described “feeling awful all the time and stated nothing is worthwhile. At the time of the interview, Hannah recounted being unhappy since age 11 and felt that she had been worsening over the previous year. As noted in this record, Hannah reported both alcohol and marijuana use but denied any history of physical, emotional, or sexual abuse.
As reported in the medical record, at age 17 Hannah’s psychiatrist began a trial of Mirtazapine, but due to extreme tiredness and lethargy chose to move to a trial of Venlafaxine which was eventually increased to 375 mg per day. Although others perceived her as improving on the medication, Hannah still reported she was unable to enjoy life and continued to experience a depressed mood and low energy. Later that year, the care provider tapered her off Venlafaxine and transitioned her to Phenelzine. Hannah experienced a number of adverse effects resulting in a dosage increase to 60 mg per day....
1. An introduction to a contemporary theory of mental health and mental illness
2. An assessment of the patient including age, gender, social and cultural factors, life history, and current circumstances. This section should be linked to the theory in your introduction.
3. A discussion of any challenges to assessing the patient described, and any further information about the patient you would need to conduct a thorough assessment based on your theory outlined in section one and should reflect listening to understand principles.
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