Mental Health Case Study

MENTAL HEALTH CASE STUDY
Introduction
The study is a mental health of a patient by the name Calvina (not real name for purposes of
protecting the patient’s identity and ensuring privacy) who suffers from mental breakdown and
depression.
Demographic profile
Ms. Calvina is 31-year old, recently unemployed after suffering mental breakdowns at her work place
repeatedly. She lives alone at Baltimore country penthouse after severing ties with her partner of 6
years.
Mode of referral
Ms. Calvina was working a consulting and logistics company, before she was fired due to her
psychotic characters. She started making lots of errors with her work and get depressed while at work
which led to her output reducing considerably. Her family and friends took her to Baltimore county
Hospital for Mental Therapy where she has been receiving immense help.
Presentation
Since Calvina was taken to the county mental health hospital by family and friends, she has been
staying there receiving the treatment required. She was diagnosed to be suffering from borderline
personality disorder (BPD). Calvina exhibited various symptoms including anger, anxiety, difficulties
in concentration, emotional impulsivity, suicidal thoughts, mood swings and self-injuries.
Past psychiatric history
Ms. Calvina has no history of suffering from mental illnesses. As family members have reported she
has never been diagnosed with any mental related illnesses. The only history the hospital of Baltimore
has is that mother died by killing herself, when Calvina was 12 years old. She had been suffering from
Schizophrenia and had been taking medication. Her mom died of drug overdose. The psychologists at
the mental hospital concluded Calvina might have inherited the mental disorder from his mother.
Forensic History
There is no forensic history of Ms. Calvina available.
Substance abuse history

Calvin has never used narcotics in her life. But it was reported that a few weeks ago she started taking
antidepressants.
Family psychiatric history
Ms. Calvina’s only reported mental illnesses in her family tree is her mother. Her mother suffered
from schizophrenia for a very long time as reported. She used to indulge in binge drinking and
inflicted injuries to herself. Calvina’s father is reported to have been missing in action throughout
Calvina’s life. It is reported that her mother and father parted ways while her mother was still
pregnant and never came to see his daughter.
Medical history
Calvina has no medical history since she has never been diagnosed with any mental disorder before.
She’s been taking antidepressants bought from the local drug sellers.
Social History
Calvina has no siblings since she was the only child of Mary Routledge and Elvis Chandler. It is
reported the Calvin has a normal and happy relationships with people surrounding her including her
maternal granny, best friend, Clara and co-workers. She spent her childhood staying with her mother
and grandmother and so it is reported that she must have watched her mother’s psychotic behaviors
including binge drinking, self-cutting her hands and wrists. At the age of 12 she witnessed the death
of her mother after taking an overdose of ecstasy drugs.
Physical assessment
Some of the physical signs observed by doctors at the Baltimore Hospital includes; increased heart
rate and blood pressure. This was because of emotional imbalance which triggered overreaction and
thus increased heartbeat rate and blood pressure. She also exhibited mood swings where at one time
she could be nice and cool and at other times she could get so angry at anybody and anything for no
reason. Doctors conducted various tests. They took her urine and blood samples for comprehensive
screening.
Mental status Examination
Appearance: slim Caucasian female looks her age, wearing blue denim tight denim jeans with
maroon top, nicely kempt long hair held in ponytail shape. Her face her no make-up, showing some
mosquito bites.
Behavior: Calvina wore a calm facial look. Other than showing restless behaviors at times, she
displayed no abnormal tendencies usually associated with mentally people. Was very engaging and
observant while talking to doctors.
Speech: She sounded calm and composed when talking and answering questions to doctors.