Assignment

CASE of GHALAN

INTAKE DATE: May 2020

IDENTIFYING/DEMOGRAPHIC DATA:

     This is a voluntary admission for this 32-year-old Black male. This is Ghalan’s first psychiatric hospitalization. Ghalan is single and is currently living with his sister. His family residence is in Nashville, TN where his sister, two nieces and one nephew reside. Ghalan graduated high school then attended a technical school for computers. In the past, Ghalan worked for seven years at the front desk of a hotel. For the past three years Ghalan has been employed at a local print shop. Religious affiliation is agnostic.

CHIEF COMPLAINT/PRESENTING PROBLEM:

     "I need to learn to deal better with my family"

HISTORY OF PRESENT ILLNESS:

     This admission was precipitated by Ghalan’s increased depression with passive suicidal ideation in the past three months. He identifies a major stressor of being furloughed from his job due to Covid-19. He was called back but with all the media attention about Covid-19 he fears losing his job. Ghalan was starting vacation from work just prior to admission and recognized that if he did not come to the hospital he did not know what would happen. Ghalan reports that in the past three months he has experienced sad mood, fearfulness, and passive suicidal ideation. He denies a specific suicidal plan. His sister reports that during the past three months prior to admission, Ghalan made a verbal suicide threat.

     Ghalan reports he has been increasingly withdrawn/non-communicative. His motivation has decreased and he finds himself "sitting around and not interested in doing chores at home". He reports decreased concentration at work and increased distractibility. Ghalan has experienced increased irritability and decreased self-esteem. There is no change in appetite. Ghalan states for many years he hasn’t slept, having a past history of working double shifts when requested. Ghalan reports his normal sleep pattern for many years has been generally three hours of unbroken sleep. He then feels tired and ends up sleeping more than his average pattern.  

Ghalan denies suicidal ideation at the present time while on the evaluation unit.

PAST PSYCHIATRIC HISTORY:

     Ghalan was seen on an outpatient basis by Dr. S, for a period of two months prior to admission. Ghalan did report periodically having the reactions over the years that he would have when he was binge drinking. It happens a couple times a year, not as often as when he was drinking. He is always concerned about them and tries to control them as much as possible. Dr. S recently referred Ghalan for inpatient treatment

SUBSTANCE USE HISTORY:

Ghalan reports a history of some alcohol binges in the past. He began drinking beer in 2008.  His pattern of drinking was to get drunk with his social group approximately twice per month. He denies a history of blackouts. Ghalan has binged with alcohol in 10 years since it was making him have a sudden surge of intense discomfort where he would tremble, have the sweats, start feeling dizzy, and have numbness in his extremities.

PAST MEDICAL HISTORY:

     Ghalan reports having been involved in a motor vehicle accident with loss of consciousness in 2004. He states he has no memory of the accident. Ghalan had a past history of fractured toes with pins being inserted in the third and fourth digits in his right foot after an accident in which he crushed his foot playing sports. Ghalan denies a past history of seizures.

     Ghalan smokes approximately one pack of cigarettes per week. Ghalan is allergic to Codeine.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY:

     Father and grandfather have a history of cardiovascular disease.

    Ghalan reports that while growing up his parents maintained a satisfactory relationship. Father reportedly worked nights and slept during the day. Ghalan did not have much contact with his father but now enjoys a close relationship with his father. He states he has always had his parents’ support.

     During Ghalan’s school years, he reports he was an underachiever in elementary school. He denies having had a history of discipline problems or hyperactivity. He states he did well in high school and earned grades of A’s and B’s. Ghalan played football in HS.

       Leisure time activities Ghalan has enjoyed in the past include playing softball, skiing, reading, playing poker, and watching football.  His sister complained that he is doing less of that now.  Ghalan states he has several close friends.

CURRENT FAMILY ISSUES AND DYNAMICS:

Ghalan ‘s sister reports that Ghalan’s difficulties began to get worse a few months ago due to Ghalan’s increasing erratic behavior. His sister Ghalan has been suffering from mood swings.

     Hi sister describes Ghalan as "extremely depressed" now and says Ghalan states, "life is over…I wish I was dead…everything I touch turns to garbage”. His sister adds that Ghalan suffers from poor self-esteem, lack of sleep and an extremely boastful attitude. On the positive side he is a good brother and uncle, compassionate, creative, and could be an outstanding person.

     The sister reports Ghalan always had a bad relationship with his mother. Ghalan is close to his father who is reported to have an alcohol problem and was allegedly loud and intimidating.

     Ghalan is currently employed by his sister’s father-in-law. Ghalan states he has financial problems now due to paying for counseling.

MENTAL STATUS EXAM:

Ghalan presents as a casually dressed male who appears his stated age of 32. Posture is relaxed. Facial expressions are appropriate to thought content. Motor activity is appropriate. Speech is clear and there are no speech impediments noted. Thoughts are logical and organized. There is no evidence of delusions or hallucinations, which Ghalan denies. Ghalan admits to a recent history of passive suicidal ideation without a plan, but denies suicidal or homicidal ideation at the present time. No manic-like symptoms are observed at the time of this examination.

     On formal mental status examination, Ghalan is found to be oriented to three spheres. Fund of knowledge is appropriate to educational level. Recent and remote memory appear intact. Ghalan was able to calculate serial 7’s.