Medical And Psychiatric Case Study

2051 Words 9 Pages
Medical and Psychiatric History
Jason fell off his house roof in 2010 resulting in loss of consciousness and short-term hospitalization. It has been suggested that this could be a factor in the decline of cognitive abilities along with excessive alcohol consumptions since his early 20s.

Jason first encountered mental health services at age 45 after being imprisoned due to breaching a protection order. Initially he was diagnosed with a major depressive episode and alcohol dependence, which were managed through the Community Alcohol and Drugs Service (CADS). Later in 2007, he was diagnosed with bipolar affective disorder type II by an outpatient psychiatrist. Most recently he has also been diagnosed with generalized anxiety disorder (GAD).
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Even though long term Jason would “love to be off all medication,” he is accepting of it helping him at this time and is wiling to continue taking them.

He is articulate and able to set appropriate goals towards recovery. Jason collaborates well with staff to develop and carry out his recovery plan.

Jason’s brother and sister are supportive. He often has weekend leave in which he stays at his brothers’ house.

Risk Assessment
Jason has a history of suicide attempt and self-harm including quetiapine overdose and attempting to stab himself, all of which have been unplanned and impulsive. He states that in the past he never planned to hurt himself. However due to his mood instability and feelings of guilt and worthlessness there is a risk that it could occur again. Currently he reports no risk of harming himself or suicidal ideation thus his risk is low.

Jason has previously self-neglected and been unable to preform ADLs. There is low risk of this occurring again due to the new skills and routine developed by Jason. He states that he fells well supported by
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Clonazepam is a high potency rapid acting benzodiazepine that is usually well tolerated by patients to alleviate anxiety (Chouinard, 2004). If Jason has attempted to use other coping strategies as described above, without any success PRN anxiolytics should be available for him in particularly stressful situations. If utilized by Jason, effectiveness and any adverse effects need to be monitored. The frequency that Jason uses clonazepam also should be monitored for signs of dependence or addiction. Jason has good insight and judgment in to his condition and is able to make sound decision regarding taking this medication.

Wellness/Recovery
Jason is a high functioning individual who is about to start discharge planning and transition into the community. Developing self-management strategies such as relaxation helps to improve personal responsibility and empowerment thus increasing success once he is in the community.

Diagnosis 3: Persistent low self-esteem related to negative self-perception, feelings of worthlessness, feelings of guilt and deterioration of close

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