formal case presentation

formal case presentation

Section 1: Identifying Information
Oscar is a 19 year old Hispanic male. He currently is a freshman at a local college majoring in agriculture. Oscar has not been married and does not have children. Oscar has been living on campus and resides with his parents when he is home on break. Oscar’s referral has come from the family based upon his hearing voices and them telling him what to do such as killing his family.

Section 2: Presenting Problem
Oscar presents with auditory hallucinations, poor hygiene, non-communication with others and paranoia. These voices have been instructing him to do things. The specific instructions kept him from completing any of his schoolwork. When the instructions ordered him to kill his family he began to isolate himself from social and familial obligations. The paranoia presents as his idea that his roommate was video taping the room when he was there. Oscar had stopped showering and started wearing multiple layers of clothing. Oscar also stopped initiating communication with others and responded to questions with one-word answers.

Section 3: Previous Treatments
Oscar was hospitalized twice before. The first time was after the family consulted their local priest about Oscar’s behaviors. The priest told them of another parishioner who is a counselor. This counselor was very alarmed over Oscar’s behavior and recommended hospitalization. Reluctantly the family relented. The first hospitalization Oscar’s psychiatrist diagnosed Oscar with major depressive disorder. A week after his discharge Oscar returned to his previous behaviors and was hospitalized again. After this hospitalization Oscar was more open and honest with the treatment team. They were than able to reassess Oscar based upon the new information he provided. Oscar was then placed into a residential facility.

Section 4: Strengths, Weaknesses, and Support Systems
Oscar has a strength in his ability to acknowledge his behaviors. He provided open and honest...

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