Case Study

Patient: XXXXXX YYYYY

Sex: Female

Birth Date: February 19, 1967

Speaks:

Place of Birth: San Francisco, California

English

Occupation: Cashier

Marital Status: Divorced

Chief Complaint:
Argument with her daughter ended up attempting suicide.
Symptoms:
Type: Heart racing, shortness of breath, cut on neck and wrist, tightness in chest
Severity: 6
Location: Mental health, neck, arms
Duration: Fight happened around 8 pm cuts happened around 8:30 pm
Factors: Family drama
History of present illness: has been admitted to the hospital about 2 times
within the past year
Allergies: none
Current drugs: inhaler, Lantus, Humalog
Smokes: yes
Drinks: occasionally
Previous treatment: yes 3 and 8 months ago
Previous medical problems: Sees a psychiatrist and support group
Surgeries: none
Diagnosis:
Upon arrival through the ER, a routine assessment was started. Further test were
taken such as
x-rays, and blood. There was no broken bones and the patients blood had a slight
level of alcohol.
There was bruising on her neck and arms. She was admitted to the hospital for
evaluation.