Medical Diagnosis Stages Examines the Patient's History (Case Study Sample)

Medical Diagnosis Stages Examines the Patient's History
Presenting Problem/Psychiatric History
The patient is a 50-year-old girl who was petitioned for delusional thinking by her brother. A psychiatrist assessed the patient, and he was involuntarily committed to Sinai Grace hospital on 10/15/20. According to the report, her brother characterized her as paranoid, believing that he and his wife were attempting to take her belongings, including her house. The patient was eventually diagnosed with schizoaffective disorder and is now undergoing treatment for it. There was no prior mental history or previous psychiatric therapy and results for the patient.
Patient's Perceptions of Stressors/Illness
During the limited interactions I had with her, she often described how her brother, along with his wife, had a hatred for her. She feels they are attempting to take from her and exploit her for her money and stuff. She relates an incident in which her brother attempted to rip a knife out of her and hurt her. She also feels ignored by the employees and thinks that no one is listening to her or dismissing her worries. Her family, on the other hand, saw her mental disorder as a fantasy.
Mental Status Exam
Appearance: patient's age and hygiene are satisfactory. Her pupils dilated, and her facial expression matched her emotions. Patient wore a crystal stone mask with no piercings, tattoos, or scars. Patient seemed to wash regularly, and her hair and nails were cut and well-groomed.
Behavior: Patient's mobility is neither excessive or restricted. On the other hand, there were no symptoms of aberrant movements or gait imbalance, nor of changed state of awareness.
Speech: Patient's speech was quick and loud. No articulation issues, slurring, sturring, or muttering.
Mood: suitable attitude and mood for the talk. Patient said she is ready to go and the staff is not helping her. During therapy, she would complain about her perceived abuse to the student nurses and other personnel.
Psychological Adaptation
Ideas of Destruction to Self/ Others: No thoughts or emotions of wishing to hurt oneself or others were reported by this patient. In fact, the patient is pleasant yet frightened when approached and participates in all group activities. No indication of self-harm, such as superficial cutting, exists. She said the only weapons in the home were knives.
Ego Defense Mechanism: The patient showed evidence of dissociation by being unable to recall pleasant recollections of her family or the personnel. Only negative feelings and recollections were expressed throughout the chat, unless the scenario was used to prove her brother and his wife were bad people. Activities like arts and crafts may help her connect to her present world and focus on reality-based thinking.
Communication/ Interaction Pattern: patient is able to effectively interact in a one-on-one and group setting for a duration of time. During brief conversations the patient can become very invested into the conversation to the point where she would not allow you to speak unless she pauses or take a breath. She is often very focused in her speech and usually the goal is to describe being wronged in some form of fashion whether it’s by the staff or the family members who petitioned her here. During the conversation she maintained intense eye contact and would use hand gestures to bring emphasis on certain points.
Psychosomatic Responses: When discussing deeper ideas and questions, the patient looks aside, indicating indifference. During the talk, the patient had no somatic problems connected to stress.
Use of Alcohol or Other Drugs: There was no reference of alcohol or drug use describe in the chart or in person.
Participation in Care: Patient Involvement in Group and Milieu Therapy Her 1:1 interaction is quite dynamic, and she speaks very clearly. She is open and ready to share knowledge with everyone who will listen, even at inopportune moments.
Previous Pattern of Coping with Stress: Patient describes exercising as a way to cope with stress and she believes it helps her release endorphins
Strengths and Limitations
When the patient needs to speak to someone because she is anxious or depressed, she has the support of her family. When she is released, the patient will have a stable place to reside and will claim to have her own house. She is a Christian who practices her faith. I did not get information on the patient's financial circumstances, employment, or educational level from her.
Health Status/Existing Conditions