Psychiatric Outpatient Clinic

Liberosis Mental Institution

Complete evaluation: by Dr. May Jones

Patient Name: Lisa Smith

Patient Number: 115

History: According to Ms. Smith's family, she has been having hallucinations since the beginning of 2017. These symptoms have been attributed to her past trauma related to parental abuse, neglect and self harm. She claims to see spirits and talk to them; they are believed to be a part of her hallucinations that she manifests in order to cope with her past. Her symptoms began after the death of her abusive father, and after she moved in with her grandparents.

Severity/ Complexity: Based on the risk of morbidity without treatment and her description of interference with
functioning, severity is estimated to be high.

Associated signs and symptoms: Her hallucinations are accompanied by severe anxiety, self harming tendencies and difficulty in concentrating.

Psychotropic Medication History: Seroquel, Latuda and other schizophrenic drugs

Allergies: There are no known allergies.

Compliance: Ms. Jones often refuses to take her medication, displaying denial of her condition.

Exam: Ms. Jones presents as inattentive, sad looking and disheveled. Her articulation and language skills are intact; she is often spotted talking to herself. There are signs of hallucinations, delusions and bizarre behavior. Suicidal ideas and intentions are present. Homicidal ideas or intentions are denied.

Diagnosis: Schizophrenia, Social Anxiety Disorder (SAD)

Instructions: Supportive therapy and medication to keep check on self harming tendencies

Cause of death: Committed suicide by slicing her own wrist with a garlic laced knife; blood loss was extreme.

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