Trauma Case Study

Trauma Case Study

Trauma Case Study

Maryam is a 17-year-old Caucasian female university student referred to your agency by her physician Dr. Jaffee. Maryam presented in her doctor’s office complaining of a lack of sleep. Dr. Jaffee did not give her medication as Maryam reportedly drinks three to four glasses of vodka and orange juice per night to sleep.

Dr. Jaffee’s report indicates the patient sleeps 2-4 hours per night and often awakens with nightmares. Blood tests were standard except for slightly elevated liver enzymes. Their blood pressure was 130/94. The patient was scheduled for a follow-up appointment in two weeks.

Behavioral observations

Maryam arrived on time for her appointment. She was driven to the appointment by her university roommate. The client appeared anxious, had circles under her eyes, and was tearful during the intake. Maryam was oriented to time, place, and person. The client’s vocabulary was above average. The client appeared tired and sad, evidenced by a low voice, soft speech, and flat affect.

Presenting problem

Maryam states, “I can’t drive a car. I am too afraid that someone will hit me or I will hit someone else. I can’t sleep so I don’t get up to class in the morning.” The client states, “I am afraid to drive.” She says, “I made such a horrible mistake; I don’t deserve to live. I am so stupid.”

The client states she was involved in a three-car accident two months ago. The client reports one person was critically injured, and the other was treated and released at the hospital. The client says she received a citation as she turned in front of two oncoming cars at a red light.

The support system of trauma case study

The client reports that she lives in student housing on the campus of a local university. She has one roommate who brought her to today’s appointment.

Legal: The client is facing legal problems due to the accident.

Family Support: Maryam’s family lives out of state. She has no relatives that live locally.