Free Case Study On Psychological Case Report (Template)

Published: 2021-07-01 09:15:05
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Category: Education, Nursing, Family, Parents, Treatment, Patient, Disorders, Bipolar Disorder

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Age __________________________
Medical Conditions(s): _______________________________________________
Reason for Referral
The patient was experiencing difficulties in getting sleep and was irritable most of the time. The patient constantly sinks into depression and has even in a number of occasions attempted suicide. Furthermore, the patient has lost interest in certain activities, which they used to like such as that of playing with friends.
Tests Administered/Test Scores & Interpretation/Behavioral Observations:
The tests that have been administered are the psychological, brain and the blood tests for bipolar disorder. The psychological test were done through the use of questions involving the level of concentration of the patient while at work and whether or not they have difficulties sleeping. The results showed that the patient could hardly get enough sleep and had lost focus in his work. A blood test was conducted in order to be able to determine the level of hormones of the patient. The result shows that the patient was suffering from hyperthyroidism because of the high hormone level of the patient. Furthermore, a brain scan was conducted and it revealed minor symptoms of what could be assumed to be a bipolar disorder.
The family history of the patient shows that one of the parents had initially suffered from bipolar disorder. There is also a history in which one of the family members had a problem with substance use. However, the main disorder that the mother to the patient was suffering from is that of depression which appears to have also been inherited by the patient.
Detailed Case History:
At the age of ten, the patient used to be disruptive in the house and at times showed physical aggression towards his younger siblings. He would even at times resort to destroying things in the house including his personal property. Later on, it was discovered that the patient had unpredictable sleeping patterns. He would experience difficulties going to sleep and would sometimes be found awake during the night. The parents became concerned to the extent that his mother decided to drop her career so she could keep an eye on the client because he appeared to be very different from his siblings. The patient was taken for psychological therapies and even blood and brain tests were conducted to determine whether the patient was suffering from bipolar disorder because of the suspicion that he might have inherited the illness from his mother. Eventually, the problem became more pronounced in his adult life because he could not focus on his work and would easily lose interest in whatever he did.
Each episode Steve has:
Axis I: Bipolar Disorder principal disorder
When the patient developed Bipolar Disorder it was signified principal disorder which is usually characterized by suicidal ideas and thoughts, gained weight, feelings of despair and sense of worthlessness. Additionally, the patient experiences symptoms such as a feeling of low self-esteem, sleepless night, he has nothing to enjoy about in his entire life. The patient seems to be experiencing isolation from people around him such as family members, relatives, colleagues, friends and coworkers. The patient also has difficulty in concentration and as the symptoms advances and even worsening over the different episodes he undergoes because they cause significant distress as well as impairment.
Axis II: Personality disorder
The patient claims that he shut out all the people around him and hide, he cries for no good reason, he is at times scared but with not strong reason and also he cannot see anything nice or good in his future. Most of the time, the patient wants to be alone and this leads him to have dark thoughts such as committing suicide since life to him has no meaning. Depression has given the patient worst days of his entire life which mostly occur in the mornings. The patient seems to hate mornings as well as himself as a result of the depression. It is evidently true that the patient would sunk in a gloom in the morning, he could laugh, he could also be animated during the evenings as well as entertain friends with mimicry which would assist him hide his true state of mind.
Axis III: Previous Treatment process or Trials
The patient responded rapidly and hastily to different forms of SSRIs at the beginning of treatment as well as the first few days of the treatment. However, after a short period the patient stopped responding to the treatment and stopped taking his daily drugs out of his own despair. This issue forced the patient to try and adapt to his earlier symptoms of depressions. Each episode experienced by the client lasted between a period of about 5 months to 7months. These episodes appeared to have seasonal preferences which disappeared suddenly and without a trace. The patient experienced a lot of these episodes which seemed to occupy him throughout rendering him busy for more than several weeks. The patient felt some improvement after taking 100mg of amitryptiline but the condition worsened again. This made the prescriber to increase the dosage to 150mg which failed again.
Axis IV: Psychosocial stressors
After the dosage, the patient spent several hours on his computer and he did not sleep for several days. The patient used to hear music from a distance throughout. The patients starts to self-medicate himself and even uses a towel wrap around his head in fear of the overheating head.
Axis V: Level of function (60-51)
The gaf score of the patient is 60-51 because the patient experienced mood disturbances which resulted to marked disruption or disturbance in either social or vocation function. The mood may not be as a result of medical condition or substance abuse.
Reason for Diagnosis:
The key symptoms the client has shown are such as that of depression, difficulties in getting sleep and because the patient is often moody. Furthermore, there is an instance when the patient attempted to commit suicide. I made my diagnosis as that of the patient suffering from a bipolar disorder because most of the symptoms like that of depression and attempted suicide point mostly to the possibility of the patient mainly suffering from the depressive episode of the bipolar disorder. Additionally, the patient is likely to have genetically inherited the disease from her mother even though such cases are very few.
Treatment Plan:
The patient will first be hospitalized in order to help manage the problem and feeling of committing suicide. The first treatment will then be given to the patient to help stabilize their moods. Secondly, the patient will receive continued treatment in order for the bipolar disorder to be contained on a long-term basis. The patient will also be given treatment on substance abuse to help manage this problem. Medications that will be used in the treatment process are such as Lithium and Anticonvulsants depending on the one that is most effective in treating the patient. These medications help in stabilizing the mood of the patient.
The patient is likely to improve in the sense that the frequency and the severity of the bipolar episodes will greatly be reduced. Furthermore, the patient will be able to focus more on their work because the medication helps to keep them focus and stabilizes their mood.

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