Major

Depression
Capstone Project - Case Study
Van Mai
N360- Fall 2016

Patient Background
34

year old male Hawaiian/ Pacific

Islander. EMS brought him hospital on
9/21/16 for intentional overdosed of 7
tablets of metoprolol XL 25 mg and
Seroquel. He has history of multiple
suicide attempts by overdosing, anoxic
brain injury related to heroin overdose
and poly-substance abuse.

Patient Background
Income source: Unemployment
Living Situation: Homeless
Legal Status: MH4

Expiration Date: 9/26/2016 at 1200
Spirituality: No religion, believed in
karma and do no harm.
Considerations r/t ethnicity or religion:
native Hawaiian/ Pacific Islander

DSM Diagnosis
I. Recurrent major depression, alcohol dependence
and amphetamine abuse.
II. None
III. - Latent Tuberculosis of the lungs (PPD + 7/28/16)
- Congenital aortic regurgitation (S/P porcine aortic
valve replacement in 2007)
- Hypertension
IV. Methamphetamine and Alcohol withdrawal
seizure. Unemployment and homeless
V. Global assessment of functioning score of 40

Patients description of
illness/issues

Major depression and severe substance abuse

(methamphetamines, alcohol and cigarettes).
Enjoys drinking and cannot stop. He stated, he drink
about half bottle of vodka/day, usually starting in the
afternoon and evening.
Lost verbal communication Had anoxic brain injury after
attempted suicide via poly-substance overdosing.
Pain on one of his foot when walking and he lost of
appetite.
I wants to die because of too many problems.
Unemployed and homeless.
Separation from his children

Patients Strengths - Limitation

Medication
compliance
Cooperative with
staf
Participate in
treatment and
therapies

Poor

adjustment skills and low selfesteem.

Maladapted coping strategies.
Abuse substances. + Sa/SI.
Unable to recognize alcohol and
substance abuse associated with
his illness, employment, financial,
family and social problems.
Isolated to self but responding
when spoken to.
Unemployment and financial
hardship
Lack of supports systems.

Medications
Clonazepam:

benzodiazepam anticonvulsant,
hypnotic. For anxiety and withdrawal seizure
prevention Total 24h dose: 1 mg. Recommended
range: 1-6 mg. L dose. Current Side efects:
Headache, insomnia
Trazodone: antidepressant for depression. Total 24h
dose: 200mg. Recommended range: 150-375mg.
Moderate dose. Current Side efects: drossiness
Melatonin: Drug class: Melatonin hormone for sleep
Total 24h dose: 3mg. Recommended range: 0.3- 5mg.
High dose. Current Side efects: Depression,
Headache.

Medications
Nicotine: Pts target sx: nicotine
cravingTotal 24h dose: 14mg/ 24hr 1
patch Recommended range 2-15 mg.
High dose Current Side efects: Headache
Isoniazid: Antituberculas. Pts target sx:
Latent Tuberculosis. Total 24h dose:
300mg. Recommended range: no more
than 300mg. Max dose. Current Side
efects: Insomnia, headache

AXIS III
1. Hypertension
2. Heart disease
3. Methamphetamine and alcohol
withdrawal seizures
4. TB lung latent
5. Hemodynamic (low H&H)

Nutritional- Bowel- Sleep

pattern
BMI:

27.02 Category: overweight

Height: 185.4
Weight: 199 lb
Consumed 75% meal and 240 ml fluid at
breakfast
Bladder & bowel status: Regular/ Normal
Sleep pattern: Awake early morning and
Difficulty falling asleep

Total sleep/24 hrs: 5.5 hr

Labs
Hbg

9/21/16

12.1% (low)
Hct 36.1 % (low)
Calcium 8.0 (low)
Blood glucose 100
ETOH 0.18
Tylenol <5
Salicylate <1
Benzodiazepam >200mg/ml

MENTAL STATUS ASSESSMENT

Behavior

- Patient was calm and cooperative, maintained intermittent eye

contact. Patient observed isolating self to peers by sitting in a corner of the room
most of the morning with minimal interaction with peers.
Affect - Displayed flat afect
Mood - Sad, discouraged, low self-esteem, depressed, irritable, hopelessness
and worthlessness, wanted to die mood, lost of interest in pleasure activities.
Sensory - Denied AH, VH, complaint of moderated headache (4 on a 0-10 scale)
and moderate visual disturbances level and the bright light make him headache.
Appearance - Clean appearance, wearing hospital clothes
Cognition- Alert and oriented to person, time, and place. Memory intact,
attention grossly intact and linear thought. Poor judgment. Fundamental of
knowledge appear to be limits
- Interpersonal relationships: client only talks to his clients brother in the
family. Client mentioned having some friends. Engaged with staf. Isolated to
peers.
- Developmental level: (Assets & barriers) Generativity vs. Stagnation stage.
Client doesnt work toward to contribute to society or to next generation. He is
self-centered and only focus on pleasure himself with addictions. Thought of
suicide

Substance abuse or
dependence
Alcohol: for 16 years
-- 500- 750ml/day
last use 9/21/14
withdrawal
symptoms:
Headache, insomnia,
mild anxiety
Cigarette: 10 years
- 13-15 Cigarette/day

Methamphetamine:
Since 2012
- last use 9/21/14
withdrawal
symptoms:
Headache,
agitation, sleep.
disturbance, HTN
3-4 times/week

PRIORITIZED PATIENT NEEDS

Risk for suicide
E: Stated he wants to die, overdosing
admission, history of multiple suicide
attempts, depressed mood.
S: Provide a safe environment and
encourage use efective coping method
to counter feeling of hopeless.

PRIORITIZED PATIENT NEEDS

Addiction to alcohol and
methamphetamine
E: Positive urine substance detection.
Admitted using alcohol, cigarette and
methamphetamine
S: Anticipate and provide appropriate
cares for possibility of withdrawal
concurrence. Encourage psychotherapy
and cognitive behavior therapy to move
forward to substance free measurement.

PRIORITIZED PATIENT NEEDS

Ineffective coping
E: Maladaptive behaviors such suicide
ideation, abuse alcohol and drugs in
response to stressors and situation.
Reported sleep disturbance, fatigue, lack of
appetite
S: Implement measures to promote efective
coping and adjustment. Assist client to
identify priorities and attainable goals as he
starts to plan for necessary lifestyle and role
changes. Behavior therapy.

Discharge Planning
Discharge

to a shelter
Continue outpatient cognitive behavior
therapy
Refrain from alcohol and
methamphetamine, smoking
Obtain skills and an employment
Establish meaningful relationship and
strengthen support network

Prognosis
Poor

prognosis
To be better:

Change his thinking and behaviors

Recognize substance use causing
problems
Need a strong social support to help him
get back on his feet.