Health Condition(s) related to this encounter (Primary, Secondary, Co-morbid, Associated)
Health Condition(s) related to this encounter (Primary, Secondary, Co-morbid, Associated)
2) Justification/Comparison of patient experience to diagnostic criteria
3) Occupations person is successfully engaged in.
4) Occupations the person has challenges in.
Case
Present Medical Record:
Maria is a 45-year-old divorced woman who presented to the ED 6 days ago s/p MVA resulting in a 5 day
inpatient hospitalization for medical stabilization, including 2 days in ICU. She was transferred to rehab
unit this morning with orders for occupational therapy to increase functional abilities.
During her inpatient stay Maria initially underwent a craniotomy for evacuation of her
traumatic SDH and had an intramedullary rod placed due to an intertrochanteric femur
fracture. Nursing and inpatient acute care records indicate patient has been labile and
impulsive. She was in physical restraints (posey vest) while in the ICU due to frequent attempts
to get out of bed, despite being non-weight bearing on L LE. Impulsivity slightly decreased on
medical floor but continued to require monitoring. Expressed passive suicidal ideation and
tearful at times. Other times noted yelling at nursing and therapy staff and refusing to
participate in care/therapy. Visits with family have been difficult, with both family and patient
leaving visits tearful. Maria is being charged with a DUI. Lab results indicate BAL was .12 in ED,
and patient confirms she was not taking her psychiatric medications (Tegretol, a mood
stabilizer, and Prozac, an antidepressant) during the past 2 weeks. She currently demonstrates
difficulty with sleep, only sleeping 2-3 hours per night.
Maria is now admitted inpatient rehabilitation. She continues to be NWB in LLE and requires
moderate assistance to maintain precautions during all OOB activities. She is unable to state
what her daily routine was prior to hospitalization and states she feels confused at times. She
states her mother is supportive but overbearing. She lives alone in a 3rd floor walkup
apartment, does not own any adaptive equipment. Is noted with loud, pressured speech, poor
physical boundaries during the interview, and irritability with interview process. Stated her
goals are to “get out of this place and get my life back”.
Medical History:
She has a history of several psychiatric hospitalizations. Her first hospitalization occurred in 2005
after an attempted suicide triggered by a breakup with a long-term partner. Throughout the
past 20 years she has been hospitalized 3 times for suicidal ideation/attempts. She is frequently
non-compliant with psychiatric medications and has a history of 2 ETOH detoxification
hospitalizations and subsequent participation in substance use rehabilitation programs.
Prior medical history is unremarkable. No other medical hospitalizations.
Social History:
Maria lives alone in an apartment but is in the same building as her mother and aunt. Mother
and aunt are supportive. They frequently provide meals, assist with cleaning, and have providedsome financial assistance intermittently throughout the past 5 years. She is divorced and has no
children. She has a few friends from AA and from school who she sees occasionally. She
graduated from college with a degree in art and has completed some graduate work toward a
degree in art therapy although recently failed the course she was taking. She has been
unemployed for 3 years. She worked for several years as an administrative assistant at a
financial services company but left her employment as a result of being counseled for
inconsistent work behaviors (arriving late or not at all without calling in, being unkempt at
times, slow work performance, and occasional rude interactions with customers and co-
workers). Recently she has had difficulty obtaining and maintaining employment and has not
been actively job seeking due to lack of motivation.
Prior to this hospitalization she has been sleeping more and spent the majority of her day
watching TV or surfing the internet. Her mother and aunt have tried to encourage her to
engage in more active pursuits including going for walks and doing art (things she typically
enjoys), but she has been mostly resistive. Mother reports she goes from no interest in cleaning
her apartment, to occasionally excessively cleaning for hours and cannot be
stopped/interrupted without an argument.
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