NR 546 Week 6 Case Study Objective The client TJ is a 48-year-old, African American male patient presenting to the emergency department with Depression, suicidal Ideation, and Alcohol Abuse History Client's Chief Complaints:

 NR 546 Week 6 Case Study

 

Objective

The client TJ is a 48-year-old, African American male patient presenting to the emergency department with Depression, suicidal Ideation, and Alcohol Abuse History Client's Chief Complaints: "I think I just want to end it all." History of Present Illness TJ presents to the emergency department with symptoms of severe depression and suicidal ideation. He reports a recent onset of overwhelming feelings of sadness, despair, and hopelessness, which have persisted for the past several months. TJ describes experiencing intense guilt and shame, often feeling like a burden to his family and friends. He admits to having recurrent thoughts of suicide, with a specific plan to overdose on prescription medication. Additionally, TJ acknowledges a long-standing history of alcohol (ETOH) abuse, which he attributes to coping with stressors in his life. He reports consuming excessive amounts of alcohol daily, often to the point of intoxication, in an attempt to numb his emotional pain and alleviate his depressive symptoms. He acknowledges that his alcohol use has worsened over the past few months, coinciding with the escalation of his depressive symptoms. He admits to drinking a pint or more of vodka a day, last drink was today. TJ reports experiencing significant distress in multiple areas of his life, including strained relationships with family members, difficulty maintaining employment due to frequent absenteeism, and financial instability. He admits to feeling isolated and disconnected Physical Examination: Height: 6' weight: 190 lb. General: Thin male appears older than stated age Lab work: AST = 67 IU/L; ALT = 43 IU/L; GGT= 36U/L; other liver function tests are WNL. Hemoglobin =12.5; hematocrit = 38; MCV =95; triglycerides = 200 mg/dl. Blood alcohol level (BAC) 0.20 mg/dL Toxicology Screen:  Positive for THC  Negative for opioids, benzodiazepines, or other substance Mental status exam: Appearance: Disheveled and unkempt, with poor grooming and hygiene. He is tearful and displays minimal eye contact throughout the examination. Alertness and Orientation: alert, fully oriented to person‚ place‚ time‚ and situation, Behavior: Agitated and restless, with frequent pacing and hand-wringing. He appears preoccupied and distracted, often losing his train of thought mid-sentence. Speech: Rapid and pressured exhibiting tangentiality Mood: Depressed. He describes his mood as "the lowest I've ever felt" and reports feeling overwhelmed by emotional pain. Affect: labile, fluctuating between tearfulness and irritability. He exhibits a flat affect at times, with limited emotional expression.

NR 546 Week 6 Case Study 03.24 MW