Reference no: EM134017015

Assignment

Jos is a 25-year-old single, Latino heterosexual male

Chief Complaint: "I am depressed and I want to do better!"

HPI:

1) "Anger", irritability, restless and anxious at times
2) Episodes of feeling depressed - while also having fatigue, reduced appetite
3) "Hard time sleeping...nightmares"
4) Endorsed feelings of paranoia, thinking that others are stalking him

Symptoms have been present "off and on" for two years

1) Family history revealed father had bipolar disorder and poly-substance use disorder, along with alcohol problems. Sister has one attempted suicide.
2) Jos is single and lives with his mother
3) Expresses some guilt due to "I can't seem to get ahead in life"

Social History

1) Employed part-time at Speedway as a cashier
2) Hx of marijuana use daily to "calm my nerves"
3) History of Meth use (thought not admitted by Jos)
4) Living with his mother and her boyfriend
5) Mother is supportive
6) Jos has no health insurance and has no Primary Care Provider
7) Jos has a driver's license but no car, and relies on his mother to drive him to work

Social History, Early Family Hx

1) Jos was born in Los Angeles ,CA
2) His parents were never married, and his dad was in and out of his life
3) Jos has lived with his mom all of his life and has one older sister and one younger sister
4) Jos graduated from High School with "average" grades; no college
5) Younger sister also lives with Jos and his mom
6) Jos's mom works full time but she makes minimum wage

Culture and Spirituality

1) When asked about preferences and any cultural values and practices that may affect his care, Jos identified the following:
2) His family is Catholic and they attend mass every Saturday
3) Jos's mom is the spiritual leader, and models and encourages the children to attend services and to be active in the practice of their faith
4) Jos's mom also demonstrates to her children that the family members be 'loyal' to one another, "to stick together..."

Past Psych History: Recent

1) Reviewing past facility records, we find that Jos has been seen by our emergency service once in the past 6 months
2) Jos had been picked up by police, placed on a "police hold due to acting bizarre, knocking on neighbors' doors, not wearing shos"
3) And he was brought to the Psychiatric Emergency Services. Get the instant assignment help.
4) Pacing
5) Bizarre mannerisms
6) Paranoid, believed the FBI was looking for him and his neighbor was stalking him
7) +Psychomotor Agitation
8) Urine toxicology was positive for amphetamines

Past Psych and Medical History

1) Jos has never been hospitalized nor treated for a psychiatric disorder
2) Jos has a history of asthma

Mental Status Exam (MSE)

1) Gait is steady. Appears overall well nourished. Appearance is mildly unkempt
2) Behavior and Attitude: Some hypervigilance, but cooperative overall
3) Mood is "irritated" per client report
4) Affect is constricted to flat
5) Thought Process is mildly tangential, he sometimes needs redirection, but redirects fairly easily
6) Thought Content shows some evidence of delusions/paranoid. No obsessions, or ruminations. No SI or HI
7) Perceptions are currently without hallucinations or other alterations and there is no sign that Jos is responding to internal stimuli
8) Attention and Concentration - Mildly distractible
9) Alert and oriented x 3

Task

Addresses the following:

I. Summarize your thoughts about Jose's situation and give examples to support your statements. Include a discussion of Jose's strengths and protective factors (Provides a summary of Jose's situation with examples; Identified strengths and protective factors).

II. What questions do you have for Jose, and what is the purpose of your inquiry? (Described questions for Jose and the goal of each question).

III. Using a Recovery-oriented care model, how would you approach Jose about some of the problem areas you see in his history? (Described a Recovery-oriented approach to caring for Jose).

IV. Describe your plan for Jose going forward - including client teaching, and include possible cultural and social factors in your plan (Discussed a realistic, person-centered, recovery-oriented plan for Jose).