Inmate Case Study Sample

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. IDENTIFYING DATA: / Inmate is a 28-year-old H/M Male incarcerated since 11/28/14, serving seven years for AGGRATED ABUSE of ELDERLY, AGGRAVATED ASSUALT LEO/FIRE/EMS, BATTERY/LEOFIRE EMS, and RESISTING OFFICER W?VIOLENCE. This is patient’s second incarceration. His TRD is 5/1/20. II. REASON FOR ADMISSION: Inmate was admitted to Lake CI MHTF from Union CI due psychotic bizarre behavior, he is utilizing hand’s movement to respond to questions, remains naked in his cell. The Inmate was extremely agitated threatening, and uncooperative. This inmate had a history of psychosis and risk of self-harm including threats to cut or hang self. Inmate refused all mental health treatment no consent and his symptoms clinically indicated the need for psychotropic…show more content…
CURRENT MENTAL STATUS EXAM: Appearance and Personal Hygiene: The inmate is a 28-year-old Hispanic male who was casually dressed in blue prison attire. Eye Contact and Mannerisms: He was calm and cooperative. He made appropriate eye contact when speaking with this examiner. His mannerisms were unremarkable throughout the interview. He was judged to be a reliable historian. Mood and Affect: His mood and affect are congruent, in which the inmate’s expression of his feelings is appropriate for the context. He became emotional and described how he wants to EOS from prison. Speech and Thought Process: His flow of thought is coherent, logical, and relevant to the topic being discussed. There was no evidence of auditory hallucinations that are self-demeaning. He denies suicidal ideation and active plan or intent. Orientation and Perception: His orientation is good. He knows the current date, place, and person. Memory and Attention/Concentration: Mr. Pastrana’s memory is intact for immediate, recent, and remote details. His attention and concentration were intact. Social Judgment: Inmate Pastrana demonstrated appropriate social judgment. He was able to interact in an appropriate manner and remained polite throughout the assessment process. Estimated Intellectual Functioning: Inmate Pastrana’s estimated intellectual functioning is deemed to fall within the moral Average range, as clinically judged, and based on his verbal fluency and educational attainment. Daily Activities: Inmate Pastrana did not endorse problems with activities of daily living nor have any been observed or reported by staff. The client shows some insight and judgment regarding his illness and need for help. The inmate is eating 3/3 meals & achieving 5-8 hours of sleep per

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