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MENTAL HEALTH CLINICAL – CASE STUDY

Mental Health Clinical Case Study

Dale Wolford

11/16/2020

Youngstown State University

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MENTAL HEALTH CLINICAL – CASE STUDY

Abstract

This Case study is based upon patient S.C. who has been diagnosed with Schizoaffective

disorder and Major Depression with Psychotic features. These diagnoses can become intertwined

and act as co-diagnosis with one affecting the other especially if medication regiment is not

consistent. Along with medication regiment other interchangeable factors that affect the patients

mental state are environment, life stressors, family history and spiritual/cultural influences. It

takes a detailed assessment of multiple areas to truly find the source of where the patient’s issues

may be coming from. Many tools and assessments will be discussed showing how a proper

treatment plan can be found. This case study will also show the many different nursing

diagnosis/interventions that are implemented to place the patient on the right path to a healthy

mental health state. Once this info. is properly identified for the patient, realistic long-term

outcomes will be placed so that he/she has goals to strive for and will hopefully keep them on the

right path.
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MENTAL HEALTH CLINICAL – CASE STUDY

Objective Data

Admission Data

The date of care provided to the patient S.C. was on September 24, 2020 and the patient

was admitted to the unit on the 21st as a voluntary patient. The patient S.C. is a 34 year old male

with a diagnosis of Schizoaffective disorder and Major Depression with psychotic features. S.C.

has a history of smoking including both tobacco and abuse of Cannabis. He also has a seizure

disorder and is overweight for his body mass index along with an allergy to Clonidine

(Catapres). The patient has handled his diagnosis relatively well for the time frame he has been

diagnosed. He has only had one previous psychiatric hospitalization being on December 12,

2019 for a behavioral admission assessment at Trumbull Regional Medical Center.

Behaviors Observed

On the day of the patients care he had a calm affect with only sometimes showing slight

emotion. The patient had seemed to be very relaxed when communicating with me, he stated to

not be hearing voices currently but was slightly short and to the point with his responses. His

facial expression was relatively fixed with only slight smirks/smiles from the conversation. He

was in a relaxed, slouching position when communicating and was very friendly to me with

responses regarding his stay on the unit. A repetitive fine motor activity he performed was an eye

squeeze to which he said was due to him being tired. Other than the repetitive eye movement

patient had reported feeling much better since arriving on the unit and restarting his medication

regiment.
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MENTAL HEALTH CLINICAL – CASE STUDY

Psychiatric Disorder

S.C. is diagnosed primarily by Schizoaffective disorder as it also groups in his other issue

of major depression to which its a characteristic of the disorder. Schizoaffective disorder is a

mental issue marked by a combination of Schizophrenia symptoms and a mood disorder. The

patient’s symptoms are primarily identified by Schizophrenia hallucinations and episodes of

depression ranging from mild to very severe. The patient had been experiencing severe auditory

hallucinations and moderate depression prior to arriving on the unit. S.C. reported having

difficulty staying consistent with medication regiment due to Covid-19 pandemic. Situations

would arise in which he would not be capable of refilling his medication due to transportation,

safety concerns and time availability.

Laboratory Values

The patient had a comprised area of four different lab values that primarily identified any

serious issues that could be occurring. Patient came in admitting to be an avid smoker to which

he was administered a urine drug screen and tested positive for Cannabis. The patient had also

had his HDL cholesterol taken to which he was chronically low at 33L (>40). TSH levels were

also taken to indicate any issues with major depression to which levels were normal at 1.14

mciu/ml. S.C. had also had his valproic acid level taken to which it was relatively low at 48.7L

(50-100 normal) indicating he has not been taking his medications. This matches up with

patient’s arrival to unit with severe symptoms returning and him voluntarily wanting to fix the

medication regiment issue.

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MENTAL HEALTH CLINICAL – CASE STUDY

Other Medical Conditions and Treatments

The patient has some other medical conditions involving a history of seizures, Anxiety

and is overweight. Pt. has not had any recent episodes of seizures but has been experiencing

fluctuating anxiety levels throughout the day making it difficult to sleep. Pt. is on Trazadone

HCL to help with sleeping at night as well as Depakote an anticonvulsant to reduce the risk for

any chance of a seizure. S.C. also has a nicotine addiction from smoking tobacco and cannabis

chronically is being treated with a Nicoderm patch for withdrawal.

Safety and Security measures

Patient is on Seizure precautions due to history of seizures and self-harm precautions as

per unit protocol with any patient. Patients are monitored continuously throughout the day and

more importance is put on those with severe suicidal ideations or at high risk or seizures. Patient

stated no issues with wanting to harm self but has had severe depressive episodes which puts him

at risk for self-harm. Patient’s main goal is to get back on track with medication regiment and

primarily be finished with his issues of auditory hallucinations. The patient has no other issues or

history with assault, sexual abuse or physical abuse to himself or others.

Prescribed psychiatric medications