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Presenting Complaint
The patient in focus is a 27-Year-old female who made her third visit to the hospital. The patient was dressed in black leggings and a blue top with tattoos and piercings on the body when brought for care. The patient had pale eyes and exhibited signs of malnourishment. She had reasonable, logical and undisturbed thoughts. The patient did not have any hallucinations and was alert with good insights and precise orientation to person time and place. She was seeking medical attention because she had severe depression and had just attempted suicide.
Occupational History
The patient is a trained accountant and used to work as an accountant in a multinational firm with the presence in five countries. She rose through the ranks to become the chief accountant. The patient complained that she lost motivation to continue working for the organization. The patient also complained about the lack of support for her role. The patient resigned from the position five months prior his visit to the hospital. The patient currently works an s cleaner in a train station to sustain his livelihood.
Relationship/ Marital History
The patient met her current boyfriend when she was 16 years old. She got pregnant and delivered a baby girl by the name Samantha. She is currently separated from the boyfriend but still considers that they are in a relationship. The patient’s daughter stays with her partner leaving her to limited access to her daughter. The patient complains that the absence of her daughter affects her esteem and hopes to be reunited with her soon. The patient claims she loves her daughter and felt bad that her condition meant she might be unable to interact with her daughter fully
Drug and Alcohol Abuse
The patient smokes about 45 cigarettes a day and occasionally drinks alcohol. Recently the patient has been drinking heavily and was engaged in a road accident, She, however, did not get any Injury from the road accident.
Forensic History/ Legal Matters.
The patient had his license withdrawn resulting from dangerous drunk driving.
Medical History
The patient has had a history of depression from the age of sixteen. She developed post-natal depression after giving birth to her daughter. Her daughter is a source of happiness to the parents. She went for treatment at a local clinic and was referred to a psychiatrist. The Patient was put on medication with Effexor; however, the drug made her erratic to the point of trying to kill the father of her daughter. The patient’s child is in the custody of her partner. She has been unable to see her child because of her current condition. The lack of access to her daughter has contributed to her depression. The patient was exposed to trauma as a child witnessing extreme amounts of domestic violence when growing up. The father was an alcoholic who physically abused the patient’s mother. The parents divorced when she was 12 years old. From a young age, she took up adult responsibilities, protecting younger sibling and performing housework. Her current depression started after meeting with her father who she had not seen for more than twelve years. She met her father with the aim of closing the chapter of her life. However, the meeting triggered all the bad memories and leading to her current state. The patient had little support from family and the hospital leading to her resignation from her job. She eventually had to settle for less lucrative jobs to survive further
Assessment Task Two 4
The patient prefers keeping to herself, She readily cooperates when asked questions and as willing to answer questions. The patient maintains eye contact and flow of thought during the discussion.
Cultural background
The patient was raised in a British household. Extreme violence characterized her early years by her alcoholic parent. The parents specifically the father who used to drink heavily and physically abuse the mother. Her mother told her that during her pregnancy her alcoholic father drove her towards drinking and may be the reason for her poor cognitive development as a child. Her birth weight was low, and she was significantly below her development milestones especially for weight and speech development. She experienced a violent home during her early childhood and had few friends to interact. She progressed well at school acquiring average grades.
Spiritual Considerations
The patient was in low spirits
General Presentation:
Patient is a 27 year old female, currently lacks a working as a cleaner with one child. Patient has a history depression and has High blood pressure; The patient complains about lack of sleep, loss of appetite, She has lost about 7kg. The patient has been admitted for attempted suicide. The patient was dressed in black leggings and a blue top with tattoos and piercings on the body when brought for care. The patient had pale eyes and exhibited signs of malnourishment. She was disturbed and looked emaciated.
The patient has normal orientation and can place the time and location for events both current and past in the context of the activity.
She had reasonable, logical and undisturbed thoughts. The patient did not have any hallucinations and was alert with good insights and precise orientation to person time and place.
denting her self-esteem. The lack of proper support system including her partner giving up on her. She began experiencing difficulty in sleeping and eating resulting in loss of 7kg of weight. She went back to the local medical clinic and on seeking treatment; the clinician gave her sertraline 100mg medication. Her partner had lost all his patience threatened to leave her. The threats overwhelmed the patient. She finally attempted suicide by use of paracetamol and prednisolone tablets. She was admitted to hospital for close monitoring and review by the psychiatrist.
Assessment Task Two 5
Mood and Affect
The patient had low spirits and wanted to be discharged to go and stay with her mother. The patient felt lonely and dejected she needed to be close to her partner.
Perceptual Abnormalities
The patient does not have any perceptual abnormalities. She can see through her current situation and is positive of the help being proposed by the psychiatrist.
Attention and Concentration
The patient has impaired attention and concentration with difficulties in keeping adequate attention spans when subjected to lengthy talks. The patient is unable to do simple subtraction and additions.
The patient claims to have amnesia both for the long-term and short-term memory. She has periods where she cannot recall anything at all. The patient states this started immediately after the time she met with her father.
The patient is aware she is suffering from depression. She is aware of the trigger to her current feelings and is positive of her ability to navigate out of her current challenges.
The patient has a clear understanding of what needs to be done to achieve the appropriate course of action. She is aware that she will need to undergo therapy to enable better treatment outcomes for PTSD


250 words

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