Ms. Case Summary

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Ms. Case is a 38 year old female who presented to the ED after wrecking her car late yesterday afternoon into a wall in a parking lot. Ms. Case Eloped from ED just prior to wrecking vehicle after refusing "headache cocktail". Ms. Case denies wanting to harm herself, she reports just having poor judgement during a anxiety attack. At the time of the assessment Ms. Case denies suicidal ideation, homicidal ideation and symptoms of psychosis. Ms. Case reports a history of PTSD, Anxiety, depression, and Schizo-affective Disorder. She reports yesterday attempting to park her car in a parking lot after experiencing an anxiety attack while driving. Ms. Case states, "I tried to slam on breaks, but I actually think I slammed on the gas." She further states, "I don't want to hurt myself." Ms. Case reports a history of multiple sexual assaults and rapes. She reports at the age of 17 she was molested by a neighbor, at the age of 24 she was sexually raped by "the east coast rapist", and another time by an unknown individual. Ms. Case reports she experiences flashback and frequently have nightmares. Ms. Case expresses symptoms of depression from these traumatic events. She expressed depressive symptoms as feelings of worthlessness, sadness, isolation, insomnia, and anger. She denies any current …show more content…

Case most recent UDS she tested positive for Marijuana, Benzo and Oxycodones. Ms. Case reports recently having surgery and having to go to multiple hospital for pain medications. She expressed multiple times she is not med seeking, however has show many med seeking behaviors. This is evidence by documentation of her frequent hospital visits and prescribe pain medications, continuous asking this clinician to make sure she gets pain medication to go home with when she has been informed this clinician dos not prescribe medications, and conflicting stories about being prescribe medications. Ms. Case also reports she smokes marijuana daily and buys 3.5 grams every 2

In this essay, the author

  • Describes ms. case's history of ptsd, anxiety, depression, and schizo-affective disorder.
  • Explains that ms. case's mother believes she was not trying to harm herself. she reports she has anxiety issues and hasn't driven in half a year since yesterday.
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