Kasus Psikososial Revised

Kasus psikososial
1. Terjemahkan
2. Identifikasi data mana yang belum di temukan(sesuaikan dengan form
pengkajian psikososial)
3. Lengkapi data tersebut, berupa tambahan data ( fiktif)
4. GP = general practitioner /Dokter umum
Case 1
Mary is aged 42 years, divorced with two children, employed part time and cares for
her mother who has Alzheimer’s disease . Past history Mary has no significant past
medical history, although she frequently makes appointments with her GP and
practice nurse about problems experienced by her and her children. She was
moderately depressed following her divorce 5 years ago and was offered anti
depressants but declined them . She was referred for Six sessions of counselling ,
which led to some improvement in her symptoms .On examination Mary complains
of feeling ‘stressed’ all the time and constantly worries about ‘anything and
everything’. She describes herself as always having been a ‘worrier’ but her anxiety
has become much worse in the past 12 months since her mother became unwell
,and she no longer feels that she can control these thoughts. When worried ,Mary
feels tension in her shoulders, stomach and legs, her heart races and sometimes
she finds it difficult to breathe. Her sleep is poor with difficulty getting off to sleep due
to worrying and frequent wakening. She feels tired and irritable. She does not drink
any alcohol
Case 2
Blossom is a 20 year old telesales operator who feels that she is
going mad with anxiety. Past history Blossom has no significant past medical or
mental health history .On examination Blossom describes feeling anxious much of
time. The problem started when she was studying for her GCSE s ,when she
describes being incapacitated with anxiety. Despite wanting to enter higher
education she felt that she would be unable to cope with the pressure and left school
aged 16. Her family was disappointed about this.Blossom describes not being able
to make decisions
as she worries too much about what would happen if she made the wrong decision.
She also describes a low mood but has no suicidal thoughts
Case 3
Jill is a 50 year -old woman who lives with her husband and two children (aged 20
and 18). She has come to see her GP with worries about a number of health
problems including extreme tiredness, agitation and pains in her chest. Past history
Jill has been a frequent attender at the practice over the years, often with concerns
about her or her children’s health. She has a history of GAD and has been on and off
antidepressants for the
past 30 years. When she was 23 she took an overdose following the break-up of a
relationship. She had some sessions of counselling about 10 years ago that she
found helpful. She was referred to a primary care mental health worker in the
practice 2
years ago for help with anxiety and low mood.She had some sessions of individual
guided self -help, but she found that this made nodifference. She was put in touch
with a voluntary sector self-help group for people with anxiety around this time –but
did not pursue this. On examinationJill says she has always been a very ‘nervy’
person who finds dealing with everyday stresses difficult. She worries a lot about
herself and her family and easily gets ‘in astate’ and assumes ‘the worst’ –for
example,if family members are unwell or if they are late coming home. Sometimes
things get so bad that she needs someone around her constantly to reassure her
and feels that she can’t be left on her own. The intensity of these problems has
varied over the years, but has become worse again during the past 8 months
following her husband’s diagnosis of heart problems. She has been drinking wine
most evenings to try to calm herself down. More recently things have become so bad
that she has sometimes felt that if she wleft on her own she might harm herself. Her
family has been very supportive and stayed with her during these periods until she
calmed down, but is now finding this difficult to manage.
Case 3
Ashraf is a 29 year - old single man who has come to see his GP Regarding feeling
stressed and exhausted all of the time, sleeping badly, having frequent headaches
and persistent worries about his work situation.Past history Ashraf describes himself
as someone who has been ‘easily stressed’ all his life.He had seen a counsellor at
college for a few sessions when he became very anxious about his exams and had
found this helpful. Apart from this he has had no previous treatment for mental health
difficulties. On examination Ashraf said that things had become significantly worse
over the past 6 months when there had been threats of redundancies in his
workplace. He describes being unable to relax, constantly thinking about mistakes
he might have made, colleagues he might have upset and what might happen in the
future. He has noticed himself getting more wound up than usual about everyday
events outside work as well. Recently he hasbeen so exhausted and anxious that he
has taken days off work, which worries him more and has prompted him to see his
GP.
Case study 4
Shubha is a 26-year-old woman who has been referred to you by the local mother
and baby clinic. You are a GP for Shubha’s husband and members of his extended
family are registered at your practice, but this is the first time that you have met her.
Shubha emigrated from Bangladesh to the UK three years ago with her husband and
his family, and gave birth to a baby girl one month ago. She has had an arranged
marriage and the family have struggled with financial pressures since the move. Her
husband is very close to his mother, who advises him on all issues related to the
baby. Shubha can speak limited English. She is unhappy about the appointment with
the GP as she feels this will bring shame to the family. She sees you – a white male
GP – with her husband, who acts as an interpreter. Her husband says that Shubha
seems unhappy and does not want to do anything. She is reluctant to get out of bed
or to look after the baby, and complains of pain in her stomach constantly. He
discloses that his mother thinks she is lazy because she is unwilling to do household
chores. Medical history Her husband says Shubha did not disclose any past
medical history to him, so her past psychiatric history is unknown. On examination
An initial physical examination does not reveal anything abnormal. A blood sample
for full blood count and testing for vitamin D deficiency are taken.
Case study 5
James is a longstanding patient at your surgery, he is 47-years-old and was

diagnosed two years ago with stage 5 chronic kidney disease due to accelerated
hypertension. He also has asthma and is Hepatitis C positive. You have not seen
James for around six months, and he is now attending a routine appointment with
you. James had been an IT consultant but is not currently working because of his
medical problems. He has been separated from his wife since 2003. Because of his
renal impairment, he is seen in an advanced chronic kidney disease clinic and he
has recently decided to have haemodialysis as his renal replacement therapy. On
direct questioning, James reports feeling very tired to the point of weariness, he says
that his memory has been affected recently, he has also had a lack of interest for his
hobbies and is finding it difficult to be able to enjoy everyday activities such as
watching the television or sharing a meal with his family.
On examination James speaks in short sentences and rarely makes eye contact.
Most of his replies are ‘yes’ and ‘no’ and he frequently needs direct questions to
prompt answers. James shows signs of poor hygiene and self care
Case study 6
Barbara is 42-year-old woman presenting at your surgery for a routine appointment.
Three years ago she was diagnosed with early stage (stage 3a) chronic kidney
disease associated with hypertension. Her kidney disease and hypertension are
managed by a combination of drugs that includes an ACE inhibitor, and dietary
restrictions. Barbara is complaining of ‘these heads of mine’ that she says make her
feel poorly, and a discomfort in her back and abdomen. Medical history Her notes
show that a previous doctor has prescribed Barbara benzodiazepines for nervous
complaints. You have treated her mother in the past for depression. On
examination Barbara describes her symptoms in a flat, monotonous voice and looks
anxious and ill at ease. You find that she uses vague phrases such as “these heads
of mine” without properly describing them. During the consultation she attributes her
symptoms to her chronic kidney disease. Further exploration reveals that Barbara is
describing headaches which she attributes to her kidney problems.
Case study 7
Fred, aged 45, is a locksmith. He has longstanding and persistent worries that he
has not done his job properly and that someone might get burgled as a result. He
worries he might have given customers the wrong change whenever they have paid
him in cash. Fred informs you that he worries about many things in his life, and his
most common thought is ‘what if’? He often imagines the worst happening and states
that when he worries, he often feels sick, has headaches, feels butterflies in his
stomach and is aware of his heart pounding. Fred often gets hot and sweaty and
says his anxiety makes it difficult to concentrate and do his job or play with his
children. He is very distressed by his constant worrying and feelings of anxiety, and
regards it as a sign of weakness. At the beginning of the consultation with his GP,
Fred states he is attending because of problems with sleeping. But after questioning
about how things have been for him recently, Fred discloses to his GP that he is
feeling under considerable stress. Medical history Fred has no medical history of
note. On examination On examination, no physical problem can be found. Fred
looks distressed and is clearly sweating despite the fact that it is not warm in the GP
surgery. The GP asks Fred how things are for him at work and at home, and Fred
mentions that he has found work a bit difficult recently. He tells the doctor he fears
his levels of stress and anxiety will cause him to make a mistake at work and
someone will get burgled. He says that he worries his stress levels will make him go
mad.
Case study 8
Paul is a 52-year-old self-employed builder who has diabetes. He presents to his GP

complaining that he has been feeling increasingly tired for the last 4 months. His
sleep is poor and he says he can’t be bothered to shave in the morning. He says that
the practice nurse was unhappy with his diabetic control and his wife has now
insisted that he see a doctor.
Medical history
Paul smokes around twelve cigarettes a day, mostly at work, with his mates. He has
hypertension and has been receiving an antihypertensive drug for the last five years.
He takes an oral statin to lower his cholesterol and an oral antidiabetic drug for his
diabetes. He also takes an ACE inhibitor for treatment of hypertension and
prevention of diabetic complications, and aspirin for the prevention of
cerebrovascular events. Paul does not regularly use alcohol, and reports drinking a
couple of pints maximum, if he is out with his mates, after a football match.
On examination
Paul looks overweight and has a body mass index of 32. When last seen by the
practice nurse his HbA1chad increased from 8% to 9.2% and his cholesterol level is
5.8mmol/l. His current blood pressure is 145/85 mm/Hg. He appears low in mood, is
avoiding eye contact and has lost his usual jocular manner. He is speaking quietly
and describes his mood as ‘fed up’. He is blaming himself for not being able to ‘pull
himself together’.
Case 9
Dan is a 32-year-old man presenting with shoulder pain. He has not been seen in the
surgery for a couple of years and in passing mentions poor sleep, annoyance about
his benefits, and dissatisfaction with his accommodation. It quickly becomes clear
that the main problem affecting Dan is mental health related, and that his shoulder
pain is related to a minor injury he sustained two or three weeks ago which is already
resolving itself. A brief history shows that he has symptoms which fulfil the criteria for
both anxiety disorder and depression. When asked how he had been in previous
months he seems a little uncertain how to answer, and then admits that he has been
in prison. On further questioning, Dan informs you that he was convicted for assault
with ABH (actual bodily harm) and resisting arrest.
Medical history
Dan was last seen in the surgery two years ago for a couple of minor complaints and
his computer records go no further back. He sees himself as always having been
well, but admits that he did see some kind of counsellor or psychologist at the age of
about 10 years old.
On examination Dan presents as reasonably smartly dressed with new casual
clothes and is cleanly shaven. He is alert but seems wary.
Case 10
Jerome has a history of anxiety and depression. He joined your surgery 5 years ago,
at which time he was taking sertraline for moderately severe depression and
associated panic attacks. This was prescribed by his previous GP. The sertraline
was effective and Jerome stopped taking the medication after 6 months of treatment.
He has not returned to the surgery since that time.
Jerome is otherwise physically fit and well and is not prescribed any medication.
On examination
Jerome describes a lack of drive and energy for the past six weeks. He feels
stressed at having to face his job but is still going to work. Jerome admits trying to
cope with disrupted sleep patterns by drinking more alcohol than usual during the
past fortnight. He is now drinking 3 pints of beer every night instead of only twice per
week as he used to. His physical examination is normal but he appears in low mood.
Case 11
Violet is 84 years old. She has been in a residential home for four months following
time in hospital with a fractured femur after a fall. She is a widow and her only visitor
has been her younger brother, who suffered a stroke six weeks ago and has not
been able to visit her since. Violet has become increasingly quiet and withdrawn.
The care staff report that she is not eating and is staying in her room much of the
time. The GP is asked to visit Violet because her weight has dropped by 4 lb in 1
month.
Medical history
Violet has Type 2 diabetes and hypertension which have been reasonably well
controlled. She is partially sighted because of macular degeneration and has
widespread joint pains from osteoarthritis.
On examination
The GP finds Violet to be alert and oriented. She looks sad and gets tearful when
discussing her feelings with the GP. She admits she is very lonely since her brother
stopped coming to see her and is worried that he may never be fit enough to come
again. She says that she is sleeping poorly, has lost her appetite and ‘can’t be
bothered’ to sit with other people in the care home – she says ‘they all get on my
nerves’. She denies being anxious or panicky and says she has never drank alcohol.
Importantly, Violet says she does not feel like harming herself, but that she does
wish that she will “just not wake up one morning”. The GP conducts a PHQ-9 with
Violet, and her score is 20. A physical examination (including chest and abdomen) is
normal, her BP is 146/82 and a dipstick urine test is negative.
Case 12
A 51-year-old female with a history of bipolar disorder presented to the ER claiming

she was feeling suicidal. She had jumped from a second story window and c/o pain
in her back and both ankles. She was alert and oriented, but combative on
admission to ED. C-collar in place, handcuffed to stretcher. “I was on the floor, my
husband was trying to hurt me, so I jumped.” “I wanted to hurt myself, and I wanted
to hurt my husband.” The police reported that the patient was aggressive towards
husband with scissors, attempted to cut self on wrists. Patient’s husband has a
restraining order against her. “She reported that her husband had been abusive to
her through the years and he recently threatened to kill her.” Her ex-husband
reported she has been deteriorating for 5 weeks, belligerent, aggressive, not
sleeping and drinking wine.On admission—the patient reported she was depressed,
suicidal, and scared. She reported a recent decreased need for sleep, euphoric
mood, and racing thoughts. Mental status: appearance—poor hygiene, disheveled;
motor activity—restless; affect—agitated; mood—depressed and anxious; speech—
soft; thought process—circumstantial; judgment—poor impulse control, maladaptive;
Insight—poor. Intelligence is below average. Concentration- distracted. Pt. suffered
multiple comminuted fractured of her left ankle and fracture of L5, these injuries
resulted from her jumping out of the second story window. Surgical intervention was
not needed but the patient was admitted to a medical surgical unit. Psych history—
she reported past history of manic symptoms along with psychotic symptoms. A
decreased need for sleep, euphoria, bizarre behavior, racing thoughts, and
increased goal oriented activity has led to hospitalizations in the past along with
paranoia. She has had 12 psych admissions, most recent admission was 2 years
ago. Reports one past suicide attempt 6 yrs. ago when she left her husband and was
in a shelter. She was discovered by staff and brought to the hospital. She then
divorced her husband. She reports an occasional glass of beer or wine, no street
drugs or abuse prescribed medications. However, her blood alcohol level was
negative and urine toxicology screen was negative. Family psych history—mother
had schizophrenia and alcohol dependence and her niece committed suicide.
Hospital course—on admission patient was depressed and reported feelings of
hopelessness, helplessness, suicidal ideation and paranoia. Patient was started on
Risperadal, discontinued from Wellbutrin as it was thought it may have been
activating the patient and inducing mixed symptoms as well as mania. Patient also
placed on Zoloft for depressed mood and continued on Depakote. Mood improved,
her affect is stabilized and her paranoia symptoms diminished. The patient remained
on the medical-surgical floor for the 13 days of her hospitalization. She was
managed very well on the unit, and did not have any behavioral problems. She was
followed by the psych NP, nurses and her MD. The nurses reported not
understanding her condition and they were wary of caring for her.
Case 13
CHIEF COMPLAINT: Cough and fever for four days
HISTORY: Mr. Alcot is a 68 year old man who developed a harsh, productive cough
four days prior to being seen by a physician. The sputum is thick and yellow with
streaks of blood. He developed a fever, shaking, chills and malaise along with the
cough. One day ago he developed pain in his right chest that intensifies with
inspiration. The patient lost 15 lbs. over the past few months but claims he did not
lose his appetite. "I just thought I had the flu." Past history reveals that he had a
chronic smoker's cough for "10 or 15 years" which he describes as being mild, non-
productive and occurring most often in the early morning. He smoked 2 packs of
cigarettes per day for the past 50 years. The patient is a retired truck driver who has
been treated for mild hypertension, bronchitis, appendicitis (as a young adult),
hemorrhoids and a fractured femur and splenic injury (motorcycle accident).
PHYSICAL EXAMINATION: The patient is an elderly man who appears tired

haggard and underweight. His complexion is sallow. He coughs continuously. Sitting
in a chair, he leans to his right side, holding his right chest with his left arm. Vital
signs are as follows: blood pressure 152/90, apical heart rate 112/minute and
regular, respiratory rate 24/minute and somewhat labored, temperature
102.6<sup>o</sup>F. Examination of the neck reveals a large, non-tender hard
lymph node in the right supraclavicular fossa. Both lungs are resonant by percussion
with one exception: the right mid-anterior and right mid-lateral lung fields are dull.
Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath
sounds, rhonchi and late inspiratory crackles (are heard) in the area of the right mid-
anterior and right mid-lateral lung fields. The remainder of the lung fields is clear.
Percussion and auscultation of the heart reveals no significant abnormality.
Examination of the fingers shows clubbing.
LABORATORY: WBC 17,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.
COURSE OF ILLNESS: Following a chest x-ray PA view and Lateral which revealed
an acute pneumonia in the right middle lobe, the patient was treated with antibiotics
as an outpatient. During the 10 days of treatment the patient's fever abated and he
felt somewhat better. A post-treatment (follow up) chest x-ray reveals a right hilar
mass. Sputum cytology demonstrates atypical cells.
Case 14
Mr George Callis is an 89-year-old man who was diagnosed with metastatic lung
cancer. George has experienced increasing symptom distress and gradual functional
deterioration. His wife can no longer care for him at home and his prognosis is short.
During the first week of George’s admission the focus is on symptom management,
support for the family and care planning with George and his family. George’s
functioning continues to deteriorate but his symptoms improve. In the second
week George develops new symptoms and his functioning becomes worse. It is
obvious that George is approaching the end of his life. At the end of the third week of
the admission George enters the terminal phase and he dies with his wife and
daughter present.
Week 1
George is alert, orientated and mobilising with the use of a walking aid. He requires
some assistance for other ADLs. The main issue is a dull, aching, and persistent
pain. The pain has significantly worsened. George is also experiencing
breathlessness but he says it has not got worse. He is experiencing some nausea,
usually after eating, and his appetite is poor. Nevertheless, George says he is not
bothered with eating. George has had some trouble sleeping, which he says is due
to pain. George also feels fatigued but says it is due to lack of sleep and getting old.
George is constipated on admission. His wife, Christella, is relieved that her husband
has been admitted. She is, however, feeling exhausted and worried about George’s
decline and increasing pain, which needs addressing urgently along with increasing
issues with his bowels and nausea. A new plan of care has been commenced to
address these symptoms. George’s daughter states that all family members
understand life limits of her father’s prognosis and the family wish for him to die here
rather than at home.
Week 2
George’s pain is now well controlled and symptoms of nausea, insomnia and
constipation have improved. Breathlessness is present but slightly improved. Fatigue
has not changed. However George has developed confusion and disorientation
especially in the evenings. The causes are complex and related to the progression
of his disease. Comfort measures to manage the new symptoms are put in place.
This includes discussing the symptoms with his family. George’s functioning has
deteriorated and he requires the assistance of two for ADLs and is spending more
time in bed. George is less communicative with staff and his wife Christella
expresses concern over changes in George’s condition and that it means he is
approaching the end of life. She feels that he is comfortable.
Week 3
At the end of this week George is experiencing fluctuating levels of consciousness,
at times responding to voice, but he is not communicating. At other times, he is not
rousable. George is unable to tolerate oral diet or medications. He requires full care
by two persons. George is restless intermittently, at times pulling at the bed
sheets. There are no signs of pain, such as grimacing, on movement. Terminal
respiratory secretions are present. Christella and her daughter are accepting of
changes once explained. George dies in the palliative care unit.
Case 14
Mrs Kathleen Davis is a 77-year-old woman diagnosed with Metastatic Endometrial

Cancer. She is living at home with her daughter, Ann. Ann is happy to care for her
mother but acknowledges that Kathleen will become more dependent over time and
it may become difficult for her to manage at home. Kathleen was referred to the
Palliative care Community Team for symptom management and supportive care. On
admission to the service Kathleen is receiving radiotherapy. Following the course of
radiotherapy she experiences a number of new symptoms relating to the treatment.
She has a period of increased symptom distress and increased care needs. This is a
difficult time for her and her daughter. By the end of the 3rd week the symptoms
either resolve or improve and the overall distress levels of Kathleen and Ann
diminish. However, Kathleen’s functioning and performance has decreased and it is
anticipated that this trend will continue and these and other symptoms will be
experienced in the near future. Kathleen remains under the care of the palliative
care team for ongoing assessment and management. A period of planned respite
care in the local palliative care unit is arranged.
Week 1
Kathleen is self-caring with some ADL’s but requires assistance to shower and
dress, she experiences mild pain in the lower abdominal region and back pain. Her
appetite is poor but her intake is reasonable; 3 small meals every day with snacks.
Ann prepares her meals. Kathleen reports recent weight loss of 3kgs. She sleeps
reasonably well. Her bowels are open every 1-2 days with regular aperients. She is
not experiencing fatigue, nausea or breathlessness at this time. She is currently
undergoing radiotherapy.
Week 2
Kathleen has developed oral thrush and her lower abdominal pain had increased
significantly. She begins to feel fatigued and her activity level has decreased, she
requires more assistance for personal hygiene. Ann begins to feel distress relating to
her mother’s changed condition and increased care needs. She is worried for her
mother during this time. Kathleen’s care plan is no longer adequate and urgent
intervention is required.
Week 3
Kathleen’s pain has improved with the change in management plan. Her oral thrush
is treated and resolved, an ongoing mouth care regime is required. There is an
overall improvement in the severity of symptoms experienced and Ann is feeling less
concerned. Kathleen however does not regain her previous mobility and activity at
this time and is generally requiring more assistance from her daughter. Ann
expresses concern about what to do if she cannot mange her mother’s future care
needs at home.
Case 15
Mr John Cleary is a 46-year-old man with Stage 4 pancreatic cancer diagnosed six
months ago after presenting to emergency with severe abdominal pain. John
received chemotherapy but his oncologist told him two weeks ago that further
chemotherapy was unlikely to be effective. John decides it is best to focus on the
time he has at home, however severe nausea and abdominal pain forces him to
present to his local Accident and Emergency one evening. John is admitted to the
oncology ward where a referral is made to the Consultative Palliative Care Team. On
admission a new care plan is implemented to manage the symptoms he is
experiencing. During the first few days Interventions are focused on managing and
assessing these symptoms as well as focusing on John and Lisa’s psychosocial care
needs including advance care planning. By day 5 John’s symptoms are greatly
improved and he wants to return home to spend as much quality time with
his wife as possible. It is expected that John will need ongoing care with likely
admissions to palliative care. He is referred to the community palliative care team to
provide support.
Day 1
John is admitted to the medical ward with increasing abdominal pain described as
sharp across his abdomen and lower back. John says the pain is unbearable and he
has had a lot of trouble sleeping. John has no strength and says he feels tired even
after he wakes from a reasonable sleep. He feels he cannot make plans because he
is so tired. John is experiencing nausea and tolerates only a small diet. He is not too
concerned about appetite or the amount of food he is eating. John has had difficulty
regulating his bowel motions. In the last two months, John has had episodes of
diarrhoea and constipation which is related to chemotherapy and the
commencement of opioid medications. John is independent with ADLs and, able to
do most activities by himself. Lisa and John were told by the oncologist to expect
John to get worse in the next few months. Lisa expressed sadness and has
trouble “coming to terms with what is happening”. Lisa is teary during the
assessment and she says it has been really difficult watching John in pain.
Day 2-4
In the first 48 hours, John has responded well to a new opioid and medication
regime. Pain has improved and John is sleeping better. Nausea is mostly improved;
however, there are still times – especially after meals – where nausea is worse. By
day 4 the new regime for bowel management is working well and pain is well
controlled.While John is able to do most activities by himself, he feels his “days are
up and down” and he has no strength.Lisa expresses much relief over John’s
improved symptoms.
Day 5
John feels quite good today and would like to return home. His symptoms have
improved. He experiences mild pain and mild nausea. There is no change to John’s
functioning and activity level. Fatigue is his main concern. John is aware that the
cancer is progressing and is feeling that his remaining time is short. He wants to
focus on his family. Lisa is pleased that John is feeling that his pain is better
controlled. She says it was such a worry for her to see him in so much pain. John
was discharged home under the care of the community palliative care team.
Case 16
M is a 32 year old man who was referred to our service by the Assertive Outreach
Team. He was living with his girlfriend but the relationship was breaking down and he
was at risk of homelessness. He was diagnosed with schizophrenia and had problems
with substance misuse. He had diabetes, which was not under control, had HIV and
Hepatitis B. M's substance misuse and health problems were the factors that put him
most at risk. He was also having to leave his girlfriend's home, with no alternative place
to stay and was too vulnerable to sustain a tenancy of his own. Moving into Forest Road
in itself addressed the immediate issue of him having a safe place to stay. We undertook
joint needs and risk assessments with his Care Team to ensure that all areas of risk and
need were being met and agreed roles and contingency plans. We put in place support
plans and worked together with M on the knowledge and skills he needed to look after
himself better. Staff also supported M to deal safely with needles for insulin. They
worked with the Dual Diagnosis team and local council on needle exchanges and
arrangements for collection of sharps boxes.
M did not understand how to budget and the choices he made about how to spend his
money often left him without the basics. His keyworker worked with him on basic
budgeting skills and his reduction in drug taking made a huge impact on his financial
position. In preparation for moving back in with his girlfriend staff ensured that all
necessary benefits were in place and M left with a budgeting plan. In the beginning, M
barely engaged in support - support was led by staff, and addressed the problems that
presented the most risk to M and others. However, once his drug taking was under
control and both physical and mental health improved, he began to care more about
himself, to lead his own support and talk about his future. He engaged in social activities
and just before he moved on, staff were supporting him to find a college course that was
of interest to him. Staff facilitated his staying in touch with his girlfriend, which later led to
them returning to living together. We have stayed in touch with M and he has continued
to sustain a tenancy and avoid debt.
Case 17
CD is a 27 year old woman with a diagnosis of schizoaffective disorder. She was
referred through the Community Forensic Mental Health Team to our specialist Forensic
Mental Health floating support service. Her offences were a series of assaults, mostly
attacks on her mother but some involving members of the public. All of these offences
were considered to be as a direct result of CD's mental health problems. She had
delusional beliefs, and periods of great excitability, anger and frustration, and also
periods of deep depression. She was referred to our service whilst living in an
accommodation based service, where she did not wish to stay. Prior to that she had
been in hospital for 14months. Whilst her mental health was not stable and a risk of
suicide was identified, CD agreed with her care team that the risk was not necessarily
increased by her living in the community and in fact she anticipated that living alone
would aid her recovery. CD had had her own tenancy before, but it had not been
successful. We developed support plans with CD, setting out how she would need to
prepare for moving out, and what her priorities were thereafter. CD was very keen to find
a home
so very much led her own support, having great clarity about the steps she wished to
take, the support she felt she needed at each stage and how quickly she hoped to
achieve this. We used the Recovery Star to help to focus the support and to measure
progress. We were agreed that we needed to start more or less from scratch with
learning about what was needed to set up and sustain a home and CD's plans involved
recognition that help would be needed from a range of other services. Along with the
practical support needed to find accommodation, access furniture projects, set up
utilities etc., we worked with CD to create WRAPs - Wellness and recovery actions plans
- whereby she identified early signs of a period of poor mental health and made plans for
how she and others should respond. CD has on-going support needs. Her mental health
does not always remain stable and her ability to cope alone is at risk when she is not
well. The risk of suicide remains and CD has plans to seek greater support when she is
able to recognise this. She still has a need for hospital admissions from time to time, but
her WRAPs have helped her to significantly reduce the need and the length of stay
when the need arises. CD's plans are to move on to live completely independently in the
future but expects to need a low level of regular support for the time being, and a
responsive, increased level of support from time to time when needed.
Case 18
AB is a 35 year old man with mental health needs and a history of alcohol misuse. He
has also been financially exploited resulting in debt and receiving threats to do with
paying the money back. His home was in a poor state and his tenancy was at risk. AB
was referred to us by the Community Mental Health Team, and their assessments
included reports of AB walking around the local area through the night, sometimes
shouting, resulting in threats from people in the local community. At first he engaged
very little in support so we worked with the CMHT, and joint sessions when his CPN
visited with medication proved more successful. Gradually we were able to consider
together his support using the Recovery Star, which enabled AB to focus on those areas
where he most needed support. Alongside supporting AB with his general physical and
mental wellbeing, our first step was to support AB to move to a different
area where he was safer and at less risk of abuse. After moving home, AB's drinking
appeared to be at a peak, which reached a head when he was admitted to hospital with
alcohol related injuries. AB found that this was the catalyst he needed to begin to
address his drinking. His keyworker supported him to make a self referral to the Dual
Diagnosis team for an assessment and he began to reduce his drinking. As his drinking
began to stabilise, we were able to support him more actively and consistently, and he
was able to begin to think more positively about his future. He began to pay more
attention to looking after himself and his appearance, and started to make his home a
more pleasant and comfortable place to live. As AB's life became more stable, we
started to work with him on a move-on plan. He began to work towards getting back into
employment, starting with some voluntary work. Already having a degree, we supported
him to explore options for retraining. He went on to attend college and he is now doing
translation work and teaching English as a second language. As AB drew closer to
moving on, we developed a 'leaving the service' support plan that set out all of the things
he needed to do and what on-going support was needed from other people and
services. We contacted him three, then six months after he left the service and he has
continued to do well. We supported AB a little over 18 months.
Case Study 19
Before Bridge Street, J had spent years of feeling unable to leave his house.
As he had already developed a trusting relationship with his OT, she encouraged him to
apply for Bridge Street. She helped J gain the confidence he needed to leave his home
and move here. He arrived with a positive attitude and hope for the future.
J worked hard with staff and his care team right from the start and quickly became
friends with other tenants, ensuring a good social network was developed within Bridge
Street. Slowly, with effort and patience, J felt more and more confident achieving tasks
alone, including travelling alone on public transport and developing a healthier lifestyle.
When J felt he was ready, he took the big step to sign up to Slimming World. This was in
August last year, and 13 months later, he had lost 12 stone. He was upset not to have
achieved 12 stone in 12 months but it shows how much he has improved in his mental
health and confidence, that he was able to shrug it off and plough onto achieve his goal
a month later.
During his time at Bridge Street, J became the one tenant all the other tenants trusted
and respected. He was the one tenant all the other tenants felt they could go to when
they were feeling low and unable to talk staff. He was the tenant whom staff asked to
speak to potential employees and tenants. He helped them feel at ease and answered
their questions knowledgably and honestly. Therefore it was no surprise that J was
asked by the project manager to come back to Bridge Street as a volunteer Project Rep,
continuing on in a role he had made his own over the last year.
J’s long term goal is to one day feel able to work as a Mental Health Support Worker. All
the staff at Bridge Street feel he would bring a lot to the role. Not only his confidence,
empathy and honesty, but his own experience with his mental health recovery will
enable him to give so much more to the role.
Here are some words from J, his family and Michelle, our manager on J and his
experience at Bridge Street.
Michelle – ‘The single words I would use to describe J are blossomed, determined and
inspiring He has changed through sheer determination and blossomed beyond all
recognition and because of this is an inspiration to all who know him.’
J’s Aunt Linda – ‘Bridge Street has given J a new lease of life, before staying there he
didn't even go out. Now he leads a perfectly normal life. This is all down to the staff at
Bridge Street.’
J’s Mum - ‘Bridge Street has been marvellous in helping J to become a more confident
and independent person. We are so grateful for their time and support.’
J – ‘Bridge Street was an amazing environment for me because I never felt judged by
anyone. Even though it is a mental health project, the atmosphere at project was that of
a very human environment. I always felt astonished that I was mixing with a bunch of
people, staff, as well as tenants, all of whom were a group of different characters that
always intrigued me. The place touched my heart and I saw a human side to myself
through Bridge Street because I saw the human side of people’s problems.
I thought to myself a lot during my time at Bridge Street that I am capable of succeeding
in life because of the support I received. Quite some years ago before I became ill, a big
part of me and my confidence was helping others. I wanted a career/job where I could
help others and get job satisfaction. When I worked as project rep, I felt my confidence
growing because I was feeling satisfied with how I was helping others in some way, if
only small. I do feel I re-gained my confidence at Bridge Street because I was re-gaining
my own personality again. I was succeeding in within myself which I hadn't felt for a
long, long time.’
Case studi 20
Tom has a diagnosis of schizo-affective disorder. He has a care coordinator in the
local community mental health team (CMHT). He uses alcohol and cannabis most
days and claims that these do not cause him any difficulties. He does not want to be
referred to drug and alcohol services.
Tom has recently become friendly with Joe, another service user who has a
significant drug (crack and cannabis) and alcohol problem. A further service user,
who lives in the same block, has reported that Joe spends a lot of time at
Tom’s flat and sometimes takes other friends there too. This service user adds that
Joe is taking money from Tom to buy his own drink and drugs, and that when he is
drunk he becomes angry and aggressive and has hit Tom.
Case studi 21
Jade has been attending the substance misuse service for several years. For the
past six months, she has been on a reducing dose of methadone and has now
completed detoxification. However, she continues to use other substances including
alcohol, crack cocaine and cannabis. Her use of these substances has escalated
since she completed detoxification, which coincided with the death of her partner
through an accidental heroin overdose. Although it is not uncommon for her to
experience feelings of suspiciousness and think that other people are talking about
her, over the past few weeks the frequency and intensity of these feelings has
increased. Jade has started to think that her neighbours have bugged her flat and
says that she has been receiving messages from the television. The mental health
lead in the service has seen Jade to assess her mental health and risks and has
identified that she has signs of psychosis25.
Case study 22
Sarah, age 7, Grade 2 Sarah started showing explosive behaviour with her teacher in Grade 2.
Her teacher has noticed that her drawings are often “dark” with depictions of dead and injured
people. There was no previous record of any problems. Sarah’s father has bipolar disorder.
Sarah’s parents were contacted and came in for an interview. Parents agreed to Sarah
being referred to a Counselor to help Sarah express her feelings and manage her anger.
A plan was put in place to identify one adult in school who could help Sarah when she
feels upset and provide a safe place for her to go. Parents were provided with some
suggestions for helping Sarah at home. Sarah’s behaviour improved and she used the
resources available to her.
Two years later, when Sarah was in Grade 4, she started exhibiting difficulty controlling
her anger; she was acting out- ran out of school, threw an object at another student, and
hid in school. At home, she was hurting her younger brother
Case study 23
Rick, age 15, high school student (Source: Dr. Ian Brown, Chief Psychologist, Durham
Catholic District School Board)
In elementary school, the other children had whispered about Rick’s rituals. He had
placed his books under his chair in the same spot every day. His pencil always had a
sharp point and was positioned at the top of his desk, exactly in the middle. An eraser
was kept on the upper right had corner, not too close to the edge. His papers always
were arranged carefully in the middle of his desk. This has continued in secondary
school.
As a secondary school student, Rick has few friends. He doesn’t like having visitors to his
house because it takes too much effort to put things back in order after they leave. He
experiences a lot of anxiety at school when furniture and equipment are moved in his
classrooms, or there is an unanticipated change in routine. Rick takes a long time to get
from one class to another and is frequently late for the start of class. He is easily upset
when other students come close to his desk; some of the other students have noticed
this and take pleasure in teasing Rick by threatening to mess up his papers.
Consequently, he frequently watches the clock and begins to pack up his belongings
several minutes before the end of the period. Lately, he has been missing a lot of his
classes, reporting that he “wasn’t feeling well”. Formerly a high achieving student (on the
work that he handed in), he is now handing in even less work than previously and is in
danger of losing his credits.
Case study 24
Marcia, age 14, Grade 9, ( Source: Dr. Ian Brown, Durham Catholic District School Board)
Marcia has just started grade nine at your school. In her first semester she attended
a school in another jurisdiction. She is vague when asked about her past, but you get
the impression that she has moved around a lot and attended several elementary
schools. You’re not sure how capable she is academically, because she produces
very little work. Much of her time in class is spent with her head down on her desk, or
looking out the window, or sketching in a notebook that she always carries with her.
When you approach her desk, she covers the notebook with a textbook and pretends
to be doing what the class is supposed to be doing. When called upon to answer a
question, Marcia nearly always has the correct response, but delivers it succinctly
and with no “feeling.” She generally avoids the other students, but has been seen
talking with Margaret, another student in three of her classes. Marcia does not go to
the cafeteria to eat her lunch, but rather sits in a corner of the library by herself. The
teacher-librarian has noticed that Marcia tends to read “dark” and “heavy” literature.
One day Margaret comes to see you at the end of the day to say that she is very
worried about Marcia. Marcia had allowed her to look at her sketchbook, and
Margaret was alarmed by what she saw.
Case study 25
Paul, age 15 , Grade 10, (diagnosed with ODD, ADHD and Bi-Polar Disorders)
Paul has recently moved into the Belleville area with his mother, step-father and two
siblings, Ela (16), and Nila (7). The family is known to the Children’s Aid Society
(CAS); two of three referral allegations were based on complaints of physical abuse
which, upon investigation, were not verified. Paul attends a special behavioural class
and recently received a one-week suspension after being caught with half a joint
(marijuana) on school property. Police were called and the CAS contacted when Paul
refused to go home.
During the initial interview at the school, Paul indicated he was slapped in the wrist,
which he considered as beating. He was scattered in his thoughts about what beating
or hitting really means and was unable to give more detailed information. He also
stated that he will be losing everything, which meant losing privileges to computer
and video games. His parents denied using any physical punishment on Paul and his
siblings; the other children supported this. Paul’s mother is aware of her son’s
challenges and has tried to help him with Big Brothers, Youth Services, and other
respite programs where she previously lived. She seems to understand that there is
no “quick fix” and she needs to learn how to manage his behaviour and mental illness
on a day-to-day basis.
Paul’s Mother, Cathy, met with school staff after Paul completed his weeklong
suspension. The Vice Principal discussed the possibility of engaging the school
board counselor to follow –up and monitor. Cathy also contacted the local Mental
Health Agency and made a request for their respite program. A completed risk
assessment indicates a high level of risk for this family. The contributing factors are
the family’s history with the Society, Paul’s developmental, mental health and
behavioural issues.
Kyle has generalised anxiety disorder. He was diagnosed at 13 years old and attends a
large mainstream high school. When Kyle was diagnosed three years ago the school met
with all the relevant internal and external agencies to develop a mental health plan to
support him. Kyle had a private psychiatrist and psychologist team supporting himself and
his family. Through this team he underwent cognitive behaviour therapy that helped Kyle to
learn relaxation techniques, replace negative thought patterns with positive thoughts and
developed his problem solving skills.
During this time, the school supported Kyle by:
 identifying step-by-step procedures to assist Kyle when he was feeling anxious;
ensuring access to key staff members and areas he could remove himself to when
overwhelmed;
 informing his teachers and staff of his needs, the strategies he was using and how to
prompt Kyle to utilise the strategies in his plan; and
 pre-warning Kyle of any changes to routine and arranged for Kyle to pre-visit or ‘walk
through’ significant new events 1 to 1 with a staff member.
At this time the school considered Kyle to be a child with a Social/Emotional Disability who
required supplementary adjustments.
Kyle is now 16 years old and has numerous strategies to manage his thoughts and feelings
and reduce his anxiety. He is displaying appropriate behaviours for his age within the school
environment. He can self-monitor his thoughts and feelings, problem solve and has
developed a range of relaxation techniques he can utilise independently.
At the beginning of the school year the student services team, including his homeroom
teacher, school psychologist and deputy principal organized a meeting with Kyle and his
parents where all of Kyle’s self-management techniques were discussed. Kyle stated he felt
confident in managing any challenges at school as long as the school continued to provide
the timetable and gave him reasonable notice of upcoming assignments and new events, as
per the usual school system. He was aware that as per the usual school processes, he
could access the school psychologist and his homeroom teacher at any point and stated that
he no longer needed any further intervention from the school outside of the usual supports
offered to the students. The staff continue to actively monitor Kyle’s progress throughout
quality differentiated teaching practice.
It was agreed that a review meeting would be held at the beginning of the next semester.
The School would enter Kylie on the Census as:
Category of Disability: ___________________________________________
Level of Adjustment: ___________________________________________

Case Study 2
Ella is a Year 1 child attending a mainstream school. Ella was diagnosed at 4 years old with
anaphylaxis to peanuts and shellfish. In collaboration with the deputy principal, Ella’s
parents have completed the Student Health Care Risk Management Plan and provided the
school with a signed Anaphylaxis Management Plan from their general practitioner and an
auto-injector. Staff have been informed of Ella’s medical needs and her management plans
and Ella is actively monitored by the staff during break times, cooking activities and
excursions to ensure she is not sharing food.
The school has a general policy about not sharing food and Ella’s parents state that she is
aware of her allergies and is generally wary of trying new foods.
To manage Ella’s risk on a daily basis the school has:
 ensured Ella’s anaphylaxis management plan is on the staffroom wall and in the duty file;
 ensured teachers, including relief teachers, are aware that it is a school rule that children
are not to share food and they actively monitor the students of this during break times;
 stored Ella’s auto-injector in a medical cabinet known to all staff;
 informed all of Ella’s teachers of her allergy and identified the need to take this into
consideration when planning any activity involving food; and
 incorporated anaphylaxis management into their excursion planning policy including that
anaphylaxis management plans and medications are always taken on excursions.
Ella’s Student Health Care Risk Management Plan and medication are reviewed and
updated on an annual basis.
The School would enter Ella on the Census as:

Case Study 3
Eddy is a Year 7 child with cerebral palsy. He has weakness in his left hand but has no
other physical impairments. Eddy is a happy, social child who is working at grade level.
The weakness in Eddy’s left hand creates some difficulty when handwriting as while he can
write with his right hand, steadying the paper with his left hand causes him to position
himself poorly, creating postural issues.
To assist Eddy the school:
 utilises a slope board with a clip to steady paper when writing/drawing;

 has discussed with Eddy strategies he can use to get assistance if required;
 ensures all door handles are well maintained so they can be opened with one hand; and
 has discussed with teachers the need to consider Eddy’s requirements when planning
their program, for example, providing a ‘tee’ and a lighter bat for Eddy when playing
softball.
Eddy’s parents and the teacher communicate via email where necessary and the school
support team meets with Eddy and his parents annually unless required sooner.
The School would enter Eddy on the Census as:

Case Study 4
Billy is a Year 3 child attending a primary school in a large country town. Billy is working
approximately two years behind grade level in most areas. While Billy’s teachers have not
ruled out a Specific Learning Disability they believe his consistent non-attendance at school
has had a significant impact on his literacy and numeracy development, this in turn impacts
on his achievement in areas such as science and humanities. The school has discussed
their concerns with regards to academic achievement and attendance with Billy’s parents.
Billy is on an IEP to address his attendance, literacy and numeracy issues. The IEP has
been sent home to his parents.
The strategies in place to address Billy’s attendance have had some success and he now
attends approximately three days per week.
The key strategies the school is using to support Billy include:
 a small group intervention program for literacy;

 a differentiated maths program to target the gaps identified in his maths concepts; and
 allowing Billy to demonstrate his content knowledge in a range of formats such as giving
verbal answers to content based questions in Science.
The school is waiting to see the impact of their teaching and learning adjustments now that
Billy is attending more frequently. They will make a judgment and possibly discuss testing
with the school psychologist depending on Billy’s progress over the next year, as at this
stage his non-attendance could be a more reasonable explanation for his low achievement
levels.
The School would enter Billy on the Census as:

Case Study 5
Jayden and Connor are both Year 2 students at a metropolitan primary school. They both
have significant delays in their academic achievement in all areas of the curriculum. Jayden
has been diagnosed with a mild intellectual disability while Connor’s parents have chosen to
not have him assessed. Jayden requires greater support than Connor to manage social
situations and undertake activities of daily living.
Connor and Jayden are in the same class and often work in a small group on a differentiated
program with and without direct support.
To support the boys to access the curriculum the teacher:
 has an IEP for each student targeting skills at each child’s current literacy and numeracy
level and implements a program targeting these skills;
 uses a task reward system with the boys combining both direct instruction and
independent activities to consolidate skills;
 supports the boys to access content material on the same topic as other students by
providing material at their reading level or providing alternate means of accessing content
such as a screen reader for specific content.
Both boys take part in regular classes for specialist subjects such as music and library but
an education assistant supports Jayden at this stage while he learns self-management skills
in less structured environments.
The School would enter Jayden on the Census as:
The School would enter Connor on the Census as:

Case Study 6
John is a pre-primary student in a regional school. He was enrolled in kindy last year but
attended rarely as he became upset and his mother decided not to persevere with sending
him as she felt he was too young. John has been attending Pre-primary for a term and a
half but still refuses to leave his mother, is reluctant to try new activities at school and often
becomes upset and refuses to participate.
John has seen an occupational therapist to address sensory processing issues in the past
and the school has observed that John appears anxious at times. His mother does not want
him to be referred to Child and Adolescent Mental Health Services or a private psychologist.
The teacher, principal and school psychologist have met with John’s mother to develop a
management plan they can put in place to assist John to manage his anxious behaviours.
Strategies include:
 identifying cues and triggers and assisting John to manage these as they arise. For
example, pre-warning John of new activities and talking him through how he will manage
them,
in-particular the management of noisy situations;
 a morning routine including John’s mother handing him over to a staff member who talks
through the day’s visual timetable with John;
 taking into account John’s sensory needs when planning class activities for example,
placing John on the edge of the group for an activity involving a lot of movement; and
 teaching John strategies to manage his anxiety such as, asking for help and breathing
exercises.
The class teacher has a communication book with John’s mother to keep communication
open but still allowing John’s mother to come and go with the other parents. A meeting at
the end of Term 3 has been arranged to review John’s progress.
The School would enter John on the Census as:

Case Study 7
Aaron is a Year 10 student at a District High School. His belongings are never organised
and he often asks to leave the class to look for personal items. Aaron will often become
defiant and raise his voice when told he can’t do something. He has a small group of
friends, who tend to encourage this behaviour. In the playground Aaron is often involved in
bullying. He is verbally abusive towards other groups of students, provoking arguments,
although they rarely escalate to any physical confrontations. Aaron will regularly return to
class highly agitated and verbally defiant of teachers’ instructions to calm down. He can
often be heard muttering swear words under his breath within adult hearing.
Aaron has a very difficult home life and the school believes a lot of these behaviours are due
to Aaron’s parents reactive parenting style based on physical discipline. Aaron’s parents
have not reported any previous mental health or medical issues that may explain his current
behaviour.
To assist Aaron to manage his behaviour the school, in conjunction with the school
psychologist, have developed a documented plan targeting a range of behaviours. Aaron’s
parents chose not to come to the meeting but have been sent a copy of Aaron’s documented
plan and invited to give feedback.
To assist Aaron in managing his behaviour the school:
 has implemented ‘Stop, Think, Do’ strategies;

 reinforces observed positive interactions with Aaron; and
 has assigned seating arrangements to reduce triggers.
All teachers have been updated and advised on Aaron’s behaviour goals and current
strategies for the classroom and playground. Consequences and incident reporting is
undertaken as per the usual school Behaviour Management Policy. A review meeting will be
held in three months time unless there is a need for an earlier review.
Given Aaron’s needs remain constant, the School would enter him on the Census as:

Case Study 8
Joseph is a Year 2 child with a diagnosis of dysgraphia. He has a history of attending

physiotherapy and occupational therapy for fine and gross motor skill development. As a
result Joseph’s pencil grip is appropriate and he uses a seating wedge to improve his
posture while sitting at the desk. After considerable occupational therapy intervention,
Joseph has developed cutting skills and can form the letters of the alphabet. His writing
remains slow and is often difficult to read due to inconsistent letter size, incorrect use of
upper and lower case letters and poor spacing.
Joseph’s teacher often finds that while Joseph has great ideas when the class is sitting on
the mat and can answer comprehension questions from his reading when asked orally, his
written output is minimal, lacks organisational structure and is significantly different to the
knowledge he displays when asked questions. Joseph’s spelling is progressing slowly but
he often requires more exposure and practice than other children with a similar reading age.
Joseph is in the lower spelling group, all of whom are on a Group Education Plan. Joseph’s
teacher has discussed Joseph’s needs with his parents.
To support Joseph his teacher ensures he:
 provides Joseph with planners to assist him to organise his ideas when writing;
 ensures Joseph’s program is pitched at his level in all areas, ie not reducing expectations
of content knowledge, maths and reading while providing writing, spelling and
organisational supports;
 allows Joseph to focus on the key skills/content by reducing unnecessary parts of an
activity ie. providing pre-ruled and dated paper in diary writing; and
 where appropriate, allows Joseph to use alternative forms of assessment such as giving
oral answers to demonstrate knowledge or using letter cards/keyboard when spelling.
As a result of his teacher’s strategies, Joseph is progressing well and maintaining
confidence in his abilities.
The School would enter Joseph on the Census as:

Case Study 9
Charlotte is a year 9 student at a large District High School. Charlotte was diagnosed as
having Type 1 diabetes when she was 4 years old and has moved to a significant level of
independent management of her medical condition. Charlotte is insulin dependent and has
a health care plan in place that is reviewed by the school nurse, her year co-ordinator,
Charlotte and her parents at the beginning of each year. Her plan is reviewed and signed by
her medical practitioner and additional meetings take place if changes need to be made
throughout the year.
However, in the last six months, Charlotte’s insulin levels have been unstable. Her medical
team is working with the school to stabilize her levels. This requires hourly testing of her
blood sugar levels, which are monitored and recorded by her teacher. The teaching staff
have noticed the impact of this on her ability to concentrate in class, which in turn impacts on
her participation and completion of classroom activities.
Currently, the strategies in place to support Charlotte include:
 Professional Learning from the Diabetes Education Officer provided staff with education
regarding diabetes in adolescents and training in the implementation of Charlotte’s
Emergency Response Plan,
 Teachers ensure Charlotte attends to her hourly blood sugar testing,
 Teachers use their PL training to observe and identify possible changes to her behaviour
which might indicate hyperglycemia or hypoglycemia,
 Teachers to reduce workload dependent on how Charlotte is feeling,
 Classroom teachers report updates on Charlotte’s progress via email on a weekly basis
to the year coordinator,
 In particular, the Physical Education teacher has a care plan to address Charlotte’s needs
when participating in physical activities, both on and off school site.
Given Charlotte’s needs remain constant, the School would enter her on the Census as:

Case Study 10
Flynn is a 16 year old boy with a diagnosis of severe intellectual disability and autism. Flynn
attends a mainstream secondary school in a large regional city but accesses some
specialised programs at the onsite Education Support Centre.
Flynn is nonverbal and typically communicates his needs using gestures, some basic signing
and visual–pictorial communication systems. He enjoys attending school but finds it difficult
to manage his sensory integration and requires significant supervision and assistance to
recognise when he needs to take a break from an activity, communicate his feelings or make
a request for assistance. His current IEP and BMP are focused on learning to learn
behaviours, functional skills in the community and transition to community based activities
over the next three years. His functional program centres on self-care, hygiene,
communication and personal safety. Flynn requires full adult assistant for all aspects of his
program.
Key learning outcomes for Flynn include:
 daily routines such as help to unpack his school bag upon arrival, and pack upon
departure;
 tolerate touch/speech cues used in the routines for greeting, meal time, toileting and
home time;
 relate concrete objects to a particular classroom activity such as nappy – toilet or bowl
and spoon – cooking; and
 indicating his needs and responding to verbal interactions.
Flynn requires extensive support to manage his behavioural responses to sensory stimuli.
He will not always act predictably to any given sensory input and therefore regular functional
behaviour analysis is performed with all staff across both sites to re-evaluate his
engagement with all aspects of his environment across all settings (school, community and
home) to ensure that Flynn is provided with a consistent set of responses and strategies that
support his changing behaviour needs.
Flynn has as one of his goals to increase his engagement with the disability service provider
in his community as chosen by his family. This requires cross training between disability
service staff and school staff to ensure that there is consistent and detailed understanding of
Flynn’s individual program. Shared professional learning, planning and collaborative case
meetings occur monthly to ensure a highly individualised transition program for Flynn.
The School would enter Flynn on the Census as:

Case Study 11
Tara is a Year 11 student enrolled at a large metropolitan secondary education support

centre. She has attended the same school since Year 8. Tara has a confirmed diagnosis of
moderate intellectual disability; she lives at home with her parents and younger sister.
Tara is very keen on becoming as independent as possible and has a goal of living
independently from home possibly in a supported, shared setting with other young people for
at least part of the time. Her individual education plan is focused on providing her with the
literacy, numeracy and independent living skills necessary to reach her goal. Her individual
education program is therefore focused on alternate literacy and numeracy around reading
for living in the community, accessing travel timetables, filling in forms and safe community
access.
Tara currently attends her work placement one afternoon a week at McDonald’s. She has
1:1 support while at work and her employer reports she is becoming more confident
completing her set work routines such as clearing and cleaning the restaurant tables with
minimal support.
To support her current work placement Tara’s program includes:
 ASDAN Work Right Program;

 participation in the People First Protective Behaviours Program;
 taking part in a weekly small group with the Community Nurse focusing on understanding
sexuality and personal care/hygiene and body functions;
 travel training to and from work;
 structured social skills program in the classroom, 1:1 skill development, structured small
group opportunities to develop the target skills and then generalisation of target skills in
the community/work settings; and
 structured social activities to support implementation of social skills at all break times and
before and after school.
Tara and her parents meet with school staff every semester, and sometimes more regularly
if any of her support team requests it. During these meetings Tara’s progress towards her
goals discussed, any refinements made and the team members provide feedback.
The School would enter Tara on the Census as:

Case Study 12
Andrew is a Year 11 student at a large rural senior high school. Andrew was diagnosed with
major depression, generalised anxiety and obsessive compulsive disorder 12 months ago.
Andrew meets with his psychiatrist every six months to review his medication which he
administers himself. He accesses a clinical psychologist weekly to receive Cognitive
Behaviour Therapy. Andrew’s teachers are aware that he has been diagnosed with a severe
mental health disorder and are very supportive of his attendance at school. Andrew has
granted permission for the School Psychologist to liaise with his doctor and clinical
psychologist to consult on school based adjustments and teacher understanding.
Andrew is currently working on a reduced curriculum focusing on core subjects with alternate
assessments. Due to his high levels of anxiety he has not attended school consistently for
the past 12 months. Andrew has developed strong functional relationships with his year
coordinator and the learning support coordinator in the school and is able to attend half days
with regular “touch base” times with either of these mentors.
Andrew’s sessions with his clinical psychologist have focused on identifying unhelpful
thoughts and replacing them with positive adaptive ones. Andrew monitors his thinking while
at school and attempts to replace thoughts and emotions that interfere with his engagement
in schooling. When he feels his thoughts are becoming compulsive he seeks out “safe
“people and areas of the school such as the school psychologist’s office before leaving the
school site. Andrew understands that if teachers notice he appears distressed or
demonstrates anxieties based behaviours that they can approach him and ask if he would
like to take a break.
Andrew’s parents, year leader, clinical psychologist and school psych communicate
fortnightly regarding adjustments to Andrews’s curriculum and self-management program in
school. The current program has seen him increase his attendance from two half days to
five half days over a 10 week period. The next term is considered by his support team to be
a stabilisation period. He is not expected to increase this attendance over the next 10 week
period.
The School would enter Andrew on the Census as:

Case Study 13
Daniel is a Year 10 boy with Duchenne Muscular Dystrophy. He has attended the same
district high school since he started school. The school has adapted to Daniel’s changing
needs as his physical condition has deteriorated. In 2013 Daniel was in a wheelchair but
was still able to toilet himself with minimal support to transfer to the toilet. While he would
become fatigued when writing and typing he was able to keep up with the mainstream
curriculum. In the 2013 census the school rated Daniel as having supplementary needs.
During 2014 Daniel has experienced a rapid deterioration in his physical condition. He now
experiences significant weakness in his arms and can no longer transfer to the toilet as
before and will require a hoist and change table. The school has recognised that Daniel will
now require further support with his self care as well as more significant changes to the way
he accesses the curriculum.
The school has held case conferences each term with Daniel, his parents, his occupational
therapist, school psychologist LSC and year coordinator for several years as well as using
email to communicate between all parties when necessary.
To ensure Daniel’s needs are being met given his recent deterioration the school discussed
and implemented the following:
 contacted the consulting teacher from School of Special Education Need Disability
(SSEND) and occupational therapist to access the required equipment such as hoists and
change tables;
 accessed training for staff and implemented Daniel’s new toileting/manual handling plan
provided by the therapists;
 accessed technology and training in the utilisation of software and hardware such as
onscreen keyboards, adapted trackpads and electronic text books/books to enable Daniel
to access the curriculum;
 modified class notes, worksheets, timetables etc so Daniel can access classroom
resources on his laptop;
 teachers where appropriate, allow alternate assignment or assessment formats such as
oral assessments; and
 school psychologist liaises with school staff and parents to discuss what school-supports
and strategies staff can put in place to assist in addressing Daniel’s social-emotional
needs.
The school has updated Daniel’s IEP and Health Care Plans to reflect these changes and
will continue termly case conference meetings to review Daniel’s progress as well as the
usual communication through emails between key parties.
The School would enter Daniel on the Census as:

Case Study 14
Zac is a 6 year old boy with Cerebral Palsy. He is in a wheelchair and totally dependent on
staff for all his self-care needs. Zac is non-verbal and currently has no reliable form of
communication apart from smiling for ‘yes’, head shaking for ‘no’ and some eye pointing for
simple choice making.
Zac does not appear to have an intellectual disability and his teacher is working hard with his
therapists to develop a communication system and the ability to better access the curriculum
through assistive technology.
To cater for Zac’s needs:
 the school holds termly case conferences with Zac’s parents and when required his
therapists, to review his IEP goals and any issues/progress;
 his teacher meets frequently with Zac’s therapists and is actively implementing therapy
programs including daily mat sessions and standing frames as well trialling
communication options;
 Zac’s staff are trained in manual handling and follow the manual handling plan provided
by the therapists for all transfers and toileting procedures;
 Zac is dependent on staff for all mealtimes and his staff are trained to implement his
meal-time Management Plan. Zac also has a Risk Management Plan to manage choking
risks;
 while Zac’s teacher finds it difficult to ascertain the extent of Zac’s ability, she ensures
that Zac is part of the regular class curriculum by modifying all questions directed to Zac
so he can answer either yes/no or can eye point between two options;
 provides Zac with a switch that he can press to gain attention; and
 Zac’s teacher also ensures that she takes into consideration physical access for Zac and
adapts when necessary.
In the short term Zac’s program will remain focused on his self-care, developing a way for
Zac to communicate and increasing his access to the curriculum. It is envisaged that once
Zac has a reliable communication system and is utilising assistive technology to enable him
to demonstrate his skills and knowledge that he will be able to access a mainstream
curriculum.
The School would enter Zac on the Census as:

Case Study 15
Russell is a Year 10 student who was diagnosed with dyslexia in Year 5. In the past Russell
has had extensive private tutoring for him at different points in his education and while his
ability to spell and his reading fluency and accuracy have improved he still has difficulty with
these skills, particularly when there are large volumes of text, he is expected to work under
time pressure or when having to remember a large number of steps/instructions in an
activity.
Russell’s school is aware that although he has difficulties in specific areas of literacy and
organisation, he is very capable in other areas. The school aims to provide a variety of
accommodations for Russell that focus on modifications and other accommodations to
promote his learning rather than reducing the academic standards and expectations.
The teaching and learning adjustments provided for Russell include:
 the use of assistive technology including screen readers and word prediction software;
 assessing content not spelling errors where the task is not a specific spelling task;
 allow the examination questions to be read to Russell and providing extra exam time in a
separate room to reduce distractions;
 provide practice exam questions that demonstrate the format of questions;
 allow for alternative presentation of exams such as less information on a page or split
exam papers to reduce fatigue;
 consider Russell’s academic load and ensure he is given assignments in advance and
assist him to time plan;
 where appropriate allow alternative assignment formats ie recorded oral reports or allow
dot points’ in writing etc;
 provide scaffolding to ensure that Russell is able to demonstrate knowledge, skills and
understanding; and
 provide explicit teaching of essay-writing formats and provide examples of well-structured
essays to the students.
While Russell still finds literacy tasks a struggle he is currently keeping up with the
curriculum requirements expected of a Year 10 student.
Given Russell’s needs remain constant until the next census, the School would enter him
on the Census as:

Case Study 16
Jamie has had very poor attendance at school having an attendance rate of 51% and having
missed the last six weeks of school. His teachers reported that when he was at school he
was having trouble concentrating in class, was easily distracted and had dropped out of his
football and basketball teams. He often complained that he was finding everything in Year
12 too hard.
At home Jamie was displaying such behaviors as staying in his room, only coming out late at
night, not attending family meals and choosing to isolate himself from friends. After being
assessed by a psychiatry registrar he was admitted into hospital. Jamie spoke to the
medical team about the voices he was hearing and described the auditory hallucinations he
was having. He was put on medication and supported on a daily basis through counseling
sessions. A hospital teacher worked with Jamie on a reduced curriculum but reported Jamie
was having problems concentrating and he was very lethargic.
As Jamie started to improve the school teams were meeting regularly to develop a plan to
support Jamie’s return to school. The pastoral care team at school liaised regularly with the
hospital team to ensure they were up to date with his progress. They were provided with
professional learning by the hospital to support their understanding of Jamie’s condition.
The school provided all the upper school staff with a half day professional learning session
on signs of psychosis and recovery.
A case conference was called with the hospital staff, relevant school staff and Jamie’s
parents to discuss his plan for a gradual return to school. Jamie would start with a couple of
lessons a week whilst he was still an inpatient at the hospital. He would be given one on
one support. Weekly case meetings would be held with both school and hospital staff to
monitor his progress and support strategies to increase his school attendance.
Jamie’s teachers met with his parents to develop an Individual Education Plan with a vastly
reduced curriculum load. This involved making decisions on Jamie’s future and whether or
how he would be able to complete Year 12. A career counselor was present at this meeting
to provide Jamie’s parents with a range of options that would be available to Jamie for his
future chosen pathway. It was decided that when Jamie felt ready a Person Centered
Planning session would be arranged to support Jamie in making new choices for his future.
Jamie’s’ parents had decided that they would then relay this information to Jamie. The
school nurse liaised closely with the hospital team to understand Jamie’s medication and
possible side effects. A risk management plan was developed to address any concerns. All
staff involved with Jamie were made given a copy of the Individual Education Plan and Risk
Management plan and were communicated with regularly on his progress at school.
The School would enter Jamie on the Census as:

Case Study 17
Tyra is a year 6 student in a large mainstream metropolitan primary school. Tyra was
diagnosed with generalised anxiety disorder in year 4. Since this diagnosis Tyra’s parents
have worked collaboratively with the school psychologist, her clinical psychologist, the
classroom teacher and the deputy principal to discuss ongoing support and the
implementation of a risk management plan.
Tyra demonstrates anxiety mostly around social situations. The classroom teacher has
observed the following:
 Tyra does not enter the classroom with all the other students;
 At recess and lunch breaks Tyra does not move far from the classroom entrance;
 Tyra avoids social interactions with most students in the class and seeks reassurance
from one student in particular;
 Tyra struggles to complete tasks given to her as she focuses on perfecting her work to a
very high internal standard;
 Tyra displays on a daily basis physical symptoms of her anxiety including short shallow
breathing, stiffening of the body and limbs, leading to reduced cognitive functioning and
emotional regulating.
The agreed strategies in the management plan are:
 Two formal case conferences will be held each term with all stakeholders present;
 A reduced workload and Tyra is given alternative options to present her work;
 Tyra’s teachers consider varied assessment methods to suit Tyra’s needs eg: oral
presentations to the teacher only, not the whole class;
 Tyra attends weekly sessions with the clinical psychologist to access cognitive behaviour
therapy;
 The school psychologist in consultation with her clinical psychologist had developed
sessions for school staff regarding the use of support languages and strategies that
complement the ongoing cognitive behaviour therapy;
 Tyra’s classroom teacher communicates regularly with her parents regarding Tyra’s
triggers and responses to strategies;
 Tyra’s classroom teacher has worked with the school psychologist to understand the
constructs and principles of cognitive behaviour therapy and reflect those with her
communication with Tyra and model helpful thinking processes in trigger situations;
 Tyra engages in the PATHS program which is delivered in a small group situation twice a
week;
 Tyra has an identified staff member who is her safe person who understands her worries
and with whom she checks in with on a daily basis;
 A buddy system has been established for recess and lunch for Tyra to encourage her to
participate in organised structured activities eg: netball game, board games. The duty
staff have been made aware of strategies to assist Tyra in the playground;
 Tyra has had seven episodes this year where she has not been able to regulate her
emotions resulting in these instances where she has not been able to reach a level of
calm for over two hours both physically and verbally.
The School would enter Tyra on the Census as:

Case Study 18
Rosie is a Year 10 student who is profoundly deaf. She attends a mainstream school full
time and is an Auslan user. She has the support of school based Teachers of the Deaf,
SSEND school psychologists and Audiologists and Educational Interpreters to implement
and provide access to the curriculum. This team also meets regularly with the mainstream
teachers and Rosie’s family. Staff from SSEND provide at least monthly support with
Rosie’s mental health as she comes to terms with her identity of being Deaf in a hearing
world. The Deaf centre staff and Rosie’s parents, communicate with each other in writing on
a weekly basis. Rosie receives a mainstream school report and it is accompanied by a
report from the Deaf centre. She has regular auditory and psychological assessments that
Teachers of the Deaf use to fine tune their individual lessons.
Rosie requires an Educational Interpreter at all times when she is in classes with
mainstream staff, and also with deaf education staff (psychologists, audiologists, speech
teachers) who don’t use Auslan and to access the curriculum. This also extends to her after
hours sport as well as socials and concerts. She tires in the afternoon, as her visual
concentration requires more muscles than using the auditory channels. Rosie requires
support with the vocabulary of her mainstream classes. She has to learn new words as well
as the new concepts being taught in the class. The level of concentration Rosie requires is
both intense and concentrated but Rosie is capable of this with appropriate assistance. She
receives additional time and support for the core subjects. As Rosie cannot take notes and
watch the Interpreter at the same time, she requires an Educational Notetaker for her core
subjects.
Rosie has an individual social skills program as well as working with the principal of the
Deaf centre once a week for individual support targeted towards appropriate and subtle
social commentary which is a linguistic issue. Role play, social stories and analysis of
behaviour in the home and at school need to be reviewed and practised each week.
Mainstream staff have attended regular professional learning regarding working with Deaf
students so that they too can remediate clumsy linguistic responses from Rosie.
Rosie does not require any assistance with personal care and travels to and from school
independently. Rosie will require surgery in the near future which may interrupt her school
program significantly. In the past, Rosie has self-harmed so all staff have received training
in four mental health programs. The school has an emphasis on teaching resilience and
positive thinking. These programs are ongoing.
The School would enter Rosie on the Census as:

Case Study 19
Alistair is a profoundly deaf student who attends a specialist Deaf centre at a mainstream
secondary college. He is in year 9. He undertakes study in the core subjects within the
Deaf centre and participates in mainstream options with extensive support.
Alistiar is non-verbal and uses Auslan based signs with prompting. He does not understand
facial expression, body language or other social cues nor can he lip read. He also finds it
difficult to read sign language. He uses the support services of school based Teachers of
the Deaf, SSEND school psychologists and audiologists, Educational Interpreters and Deaf
mentors to implement and provide access to the curriculum. This team also meets regularly
with mainstream teachers and Alistair’s family to ensure he is motivated and “comfortable”.
“Comfort” for a deaf student means that they are not stressed by the environment and can
therefore maintain eye contact.
He appears stressed when over stimulated and prefers not to watch and/or mix with others.
Alistair has sensory and socialisation issues. Officers from SSEND provide monthly support
with Alistair’s mental health as he learns how to deal with each new context he faces.
Communication between his Teacher of the Deaf and with Alistair’s family occurs daily or
weekly as deemed necessary, as Alistair has very low communication skills. Alistair
receives a report from the Deaf centre as well as a report from his mainstream options
classes. These reports are also translated into sign language on disc so he can understand
his own progress.
Alistair requires an Educational Interpreter at all times. In addition, he requires a deaf

mentor to relay the Educational Interpreter’s message. He tires easily in the afternoon as
many deaf students do, because his visual concentration requires more muscles than the
auditory channels. Alistair requires support with the vocabulary of his mainstream classes.
He is learning new words at the same time as new concepts which hearing students do not
need to do. Alistair requires tuition in a small class of six students but must be accompanied
by his Educational Interpreter and Deaf mentor. He will work quietly on task if he has the
appropriate support.
Alistair initially required 1:1 support 100% of the time, but this has reduced slightly to 90–
95% and he responds positively with that amount of support. He finds it difficult to work
independently at any time. His intellectual functioning indicates good non-verbal skills which
allow the school to build on this skill to give Alistair challenges at school. His literacy and
numeracy skills are at a very low primary school level. However, with support, his
photography skills are excellent.
Alistair has access to a small withdrawal room if he requires a break and time away from
other people. This is particularly useful if he cannot make it through the whole of the
mainstream classes. The Deaf centre rooms do not have the visual or auditory distractions
found in the mainstream classes.
At recess times Alistair prefers to stay by himself and just observe the other students. He
does not attempt to communicate with others without being prompted. The Deaf centre
provides staff on duty to encourage him to communicate with his peers.
The School would enter Alistair on the Census as:

Patient Mr. NCS is a 53 year old Chinese man with the height of 1.72m, and weighs 82kg
where his BMI is 27.7kg/m2 (overweight). Patient runs his own business and is currently
staying with his wife and 3 children. He claims that he does not smoke and does not drink at
all. According to the patient, the paternal side of his family has family history of hypertension
and kidney failure where else for the maternal side, hypertension was known to be the family
history. Patient has no known drug or food allergy.
Patient was known to have had hypertension 15 years ago and also a history of pulmonary
tuberculosis 35 years ago. Patient denied of being diagnosed with diabetes mellitus in the
past. As for drug history, patient was only on 10mg of lovastatin (tablet) once at night and
according to the patient, he was compliant to the medication.
1.2 Clinical Progress

Patient was admitted into Accident and Emergency department and complained of shortness
of breath (SOB) and mild giddiness. He also complained of having chest pain and a first
episode of shortness of breath earlier before he was admitted into the hospital. On
examination, he was found to be alert and conscious. Venous blood gas sampling was done
and pH was found to be 7.306 (low), pCO2 was 44.2mmHg, pO2 was 45.8mmHg and HCO3
was 24.7mmol/L. Blood pressure was found to be 157/95mmHg, pulse rate was 72bpm,
SPO2 was 97%, body temperature was 35.4°C and respiratory rate was 21 breaths per
minute. Reflo value was also obtained and it was found to be 17.1mmol/L and blood ketone
was 0.9. Lungs were clear and abdominal was soft and non tender. Cardiovascular testing
was done and it showed dual rhythm no murmur. The initial impression of this patient by the
general practitioner in the hospital was impending diabetes ketoacidosis. Patient was
immediately given 6 units Actrapid subcutaneously and the GP also planned to give O2
3L/min and to prescribe GTN 1/1 subcutaneously and Aspirin 1/1.
Later on day 1 of admission, patient complained of increased in sweating, shortness of breath,

body weakness and vomiting for 3 times in the morning. Patient's blood pressure was 123/76,
pulse rate was 82bpm, SPO2 was 99% and respiratory rate was 20 breaths per minute. When
patient was asked, he mentioned that he has not done body check up and blood pressure
measurement for at least 5 years now. Later in the afternoon, patient complained of excessive
sweating and lack of appetite for the past 3 days. Patient then denied of having any chest
discomfort or shortness of breath, headache and abdominal pain. Besides that, patient also
complained of having polyuria and needed to wake up more than 3 times at night for
micturation. He also complained of having polydypsia, lethargic and vomiting for 2 times in
the morning. Patient was examined and he was found to be alert and conscious where he
responded fully to Glasgow Coma Scale (GCS). Patient was also found to have good
hydration and his capillary refill time (CRT) was less than 2 seconds. Vital signs were
obtained and temperature was back to normal, 37°C, blood pressure was 151/69, SPO2 was
97%, pulse rate was 88bpm and reflo value was 14.6. The management plan by the local GP
was to continue monitoring the reflo value, prescribe 10mg lovastatin (tablet) once at night
and 10mg amlodipine (tablet) once daily and have the patient to rest in bed. As patient was
able to tolerate orally, IV drip was off and patient was allowed to take fluid orally.
On day 2, patient was found to be comfortable. However, patient complained of having poor
oral intake and that he was sweating profusely. He was still feeling mild giddiness and
lethargic but no more chest or abdominal pain. Vital signs were observed and temperature
was 37°C, blood pressure was 128/84, pulse rate was 96bpm and reflo was 14.9mmol/L.
Fundoscopy was also done and patient was found to not have any signs of retinopathy and
chest X-ray was found to be clear. The management plan for day 2 was to continue 10mg
amlodipine once daily, allow fluid intake orally, continue reflo monitoring 4 hourly and to
trace and review the fasting blood sugar (FBS). On examination, patient was found to be alert
and responded well to the GCS with the score of 15/15. Blood pressure was taken and it was
145/100 when patient was lying down and 130/90 when patient was standing. Renal profile
was normal except for low potassium level of 3.0mmol/L. Impression for this patient was
newly diagnosed diabetes mellitus.
Further management plan for this patient was to conduct a stress test on patient after
discussing with the specialists and to monitor patient's blood pressure for both lying down
and standing up position 4 hourly for a day. Further plan was to start 500mg metformin
(tablet) twice daily, 150mg aspirin (tablet) once daily, 20mg lovastatin (tablet) once at night,
trace urine full examination microscopic examination and to refer the patient for diabetic
counseling. Besides that, local GP also decided to off amlodipine and to change it to 4mg
perindopril (tablet) once daily.
Table 1 : Patient's laboratory findings on Day 2.

Sodium 129 mmol/L â†“ [135 - 145mmol/L]
Potassium 3.0 mmol/L [ 3.5 - 5.0mmol/L]
Creatinine 83 Âµmol/L [27 - 62 Âµmol/L]
Glucose fasting 14.1 mmol/L [3.9-5.0mmol/L]
Total Cholesterol 5.7
HDL 0.82
Triglycerides 6.7
AST 24 IU/I [10-37IU/I]
ALT 45 IU/I [10-65IU/I]
Bilirubin 11 Âµmol/L [2-24 Âµmol/L]
INR 1.03
Trop I 0.02
CKMB 0.5
Case study
A 51-year-old female with a history of bipolar disorder presented to the ER claiming she was feeling suicidal.
She had jumped from a second story window and c/o pain in her back and both ankles. She was alert and
oriented, but combative on admission to ED. C-collar in place, handcuffed to stretcher. “I was on the floor, my
husband was trying to hurt me, so I jumped.” “I wanted to hurt myself, and I wanted to hurt my husband.”
The police reported that the patient was aggressive towards husband with scissors, attempted to cut self on
wrists. Patient’s husband has a restraining order against her. “She reported that her husband had been abusive to
her through the years and he recently threatened to kill her.” Her ex-husband reported she has been deteriorating
for 5 weeks, belligerent, aggressive, not sleeping and drinking wine.
On admission—the patient reported she was depressed, suicidal, and scared. She reported a recent decreased
need for sleep, euphoric mood, and racing thoughts. Mental status: appearance—poor hygiene, disheveled;
motor
activity—restless; affect—agitated; mood—depressed and anxious; speech—soft; thought process—
circumstantial;
judgment—poor impulse control, maladaptive; Insight—poor. Intelligence is below average. Concentration-
distracted.
Pt. suffered multiple comminuted fractured of her left ankle and fracture of L5, these injuries resulted from
her jumping out of the second story window. Surgical intervention was not needed but the patient was admitted
to a medical surgical unit.
Psych history—she reported past history of manic symptoms along with psychotic symptoms. A decreased
need for sleep, euphoria, bizarre behavior, racing thoughts, and increased goal oriented activity has led to
hospitalizations
in the past along with paranoia. She has had 12 psych admissions, most recent admission was 2 years
ago. Reports one past suicide attempt 6 yrs. ago when she left her husband and was in a shelter. She was
discovered
by staff and brought to the hospital. She then divorced her husband.
She reports an occasional glass of beer or wine, no street drugs or abuse prescribed medications. However,
her blood alcohol level was negative and urine toxicology screen was negative.
Family psych history—mother had schizophrenia and alcohol dependence and her niece committed suicide.
Hospital course—on admission patient was depressed and reported feelings of hopelessness, helplessness,
suicidal ideation and paranoia. Patient was started on Risperadal, discontinued from Wellbutrin as it was thought
it may have been activating the patient and inducing mixed symptoms as well as mania. Patient also placed on
Zoloft for depressed mood and continued on Depakote. Mood improved, her affect is stabilized and her paranoia
symptoms diminished. The patient remained on the medical-surgical floor for the 13 days of her hospitalization.
She was managed very well on the unit, and did not have any behavioral problems. She was followed by the
psych NP, nurses and her MD. The nurses reported not understanding her condition and they were wary of
caring
for her.
Case study
31-year-old woman with a history of: depression; seizure disorder; anemia; diabetes; hypertension; end stage
renal disease; polysubstance abuse and malfunction of hemodialysis catheter.
When the patient was age 14, she was diagnosed with diabetes, this led to hypertension; she had a son at age
21 and the pregnancy led to kidney failure and the need to go on dialysis. She has since had several access
revisions.
The patient also reported having a history of depression, anxiety and post-traumatic stress disorder (but
would not elaborate).
When I first introduced myself to this patient, she was very angry and was facing away from me, staring at the
wall. She was on isolation for MRSA and VRE and this truly made her feel more isolated. I asked if I could
assist
her with anything and she said she needed some sheets on her bed so she could lie down and she needed
pain medication. She was very itchy and needed the linens washed in Ivory. I offered to go and collect the sheets
from housekeeping and when I came back with the sheets, she was then engaging and no longer angry and we
spoke. Through my actions, I demonstrated caring and this is extremely important to remember as nurses [4].
The patient wanted to take Ambien (a sleeping medication) at 3:00 pm. The nursing staff was incorrectly
viewing this as drug seeking behavior. She did not truly want to take Ambien at 3 pm, but was trying to express
how poorly she felt and she wanted the nurses to understand this.
Case study
78-year-old man with sudden onset of RUQ pain woke him up from sleep at 2:30 am. The pain was sharp,
non-radiating, no fever, chills, n/v. An abdominal ultrasound showed a fatty liver, gall stones and gall bladder
dilation. The relevant lab results were: AST-555; ALT-482.
His past health history includes the following: gout; high cholesterol; schizophrenia; hyperlipidemia; type 2
diabetes; GERD and previous major depressive breakdowns which required prolonged psychiatric
hospitalizations.
The admitting diagnosis was acute cholecystitis, cholelithiasis. The medications he took at home are: Prilosec;
Haldol; Depakote; Lipitor; metformin. After medical clearance, he will have laparoscopic cholecystectomy.
The patient was very angry that his wife told the staff that he had a psychiatric problem, because he thinks
mental illness has a stigma. When the nurse offered his nighttime Haldol medication, he refused and said “I
don’t take that!” So, he refused his medication in a hospital because he was embarrassed and felt that mental
illness
was a stigma. He didn’t trust the system, he didn’t trust the nurses.
Case study
History: Jane Wheels

Jane Wheels is a 24-year-old married female who presents to her nurse practitioner
reporting lower abdominal pain, cramping, slight fever, and dysuria of four days duration.
• 24-year-old G1P1, LMP two weeks ago (regular without dysmenorrhea).
• She uses oral contraceptives (for two years).
• She reports a gradual onset of symptoms of lower bilateral abdominal discomfort,
dysuria (no gross hematuria), abdominal cramping, and a slight low-grade fever in the
evenings for four days.
Discomfort has gradually worsened.
• Denies GI disturbances or constipation. Denies vaginal discharge. Took
acetaminophen for fever (three doses).
• Jane states that she is happily married in a mutually monogamous relationship and
plans another pregnancy in about six months. Husband does not use condoms. Reports
that they engage in vaginal sexual intercourse approximately two times per week—no
oral or rectal sex.
• Cooperative and good historian. Non-smoker, exercises regularly, no appetite changes,
no travel outside the U.S., and no history of STDs. Reports occasional yeast infections.
Douches regularly after menses and intercourse. Reports douching last this morning.
Physical Exam
• Vital signs: blood pressure 104/72, pulse 84, temperature 38°C, weight 132 lbs.
• Neck, chest, breast, heart, and musculoskeletal exam within normal limits. No flank
pain on percussion. No CVA tenderness.
• On abdominal exam the patient reports tenderness in the lower quadrants with light
palpation. Several small inguinal nodes palpated bilaterally.
• Normal external genitalia without lesions or discharge.
• Speculum exam reveals minimal vaginal discharge with a small amount of visible
cervical mucopus.
• Bimanual exam reveals uterine and adnexal tenderness, as well as pain with cervical
motion. Uterus anterior, midline, smooth and not enlarged.
Case study
29 year old G3 P1 EDD 3/16 with history of cHTN and previous history of preeclampsia with
severe features (delivery at 35 weeks)
-Previously discussed increased risk of developing preeclampsia (30%) and other risks associated
-Patient did not like side effects of Labetalol, therefore self discontinued
-Continue Atenolol 25mg daily. Previously discussed potential for growth restriction but will
monitor growth q4 weeks. Continue ASA 81mg
-Antenatal testing with weekly NST beginning at 32 weeks gestation
-Delivery in the 39th week of gestation, unless earlier delivery is indicated.
Severe Nausea and Headaches, concerning for migraines
-Uses Fioricet PRN. The patient reports this is what she will continue as this is the only thing helping
-previously referred to neurology for chronic management of headache.
Obesity- Class 2 BMI 41 (201 lbs, 5ft2in)
-recommend <15lb weight gain this pregnancy
-discussed importance of diet and exercise in pregnancy
Solitary kidney
-s/p laparoscopic left nephrectomy in 2003
-Done for "atrophic kidney" in the setting of labile blood pressures
-Nephrology consult revealed a healthy kidney by both blood tests and US
-Baseline creatinine 0.9 - continue to monitor monthly throughout the pregnancy
Depression/Anxiety:
-Continue Fluoxetine and Diazepam (previously counseled on risks)
-patient referred to women's wellness clinic previously
-continue mood checks
Herpetic Whitlow
-Continue acyclovir 800 mg daily
Palpitations
-EKG and echo Maternal echo WNL with EF 59%, normal LV wall thickness
-Cardiology diagnosed her with exercise intolerance. No clear etiology. Recommend blood
pressure control at this time.
Subclinical hypothyroidism
Prenatal Cares
-Continue daily prenatal vitamin
-Tdap vaccine to be administered between 27-36 weeks gestation, offer at next visit
-Declined influenza vaccine
Baseline studies
24 hour urine protein. 220mg
AST/ALT 17/15
HCT:39 Plt 282
Cr.0.9
EKG sinus tachycardia
Maternal echo WNL with EF 59%, normal LV wall thickness
Weeks Blood pressure Weight
7w1d 142/83 mmHg 91.4 kg
11w1d 147/89 mmHg no weight gain
14w3d 148/91 mmHg 91.8 kg
18w1d 143/91 mmHg 91.3 kg
20w1d 134/80 mmHg 91.9 kg
23w3d 122/67 mmHg, 93 kg , EFW:591gm (50%)
136/74 mmHg,
27w1d 139/98 mmHg 97.3 kg, EFW 959gms(41%)
Event
Five days prior to admission:
Calls nursing triage with headache from sinus infection
Goes to Quick Care
• Has headache
• Right upper quadrant pain
• SOB
• B/P 180/120
Receives z-pack and albuterol inhaler

Arrival to Emergency department
Awake and alert 29 y.o G3 P01,1,1 EDD 3/16/2015 29.6 weeks patient arrives in emergency
department with severe right upper quadrant pain that started 1.5 hours ago. Patient also has c/o
headache and blurry vision. Patient had gone to Quick Care 5 days prior with right upper
quadrant pain and SOB. Per patient BP was 180/120. She was given an albuterol inhaler and
sent home. Patient continued to have symptoms with acute worsening of the epigastric pain 1.5
hours before arriving to hospital. In the ED patient was severely hypertensive with SBP >200.
Transferred to LDR. Temp 36.5 HR 80 RR 20 B/P 191/118.
Labor and delivery Late entry due to patient condition. At 1828 patient arrives from ER with
severe right upper quadrant pain, accompanied by____. Patient also complains of headache and
blurry vision at this time. She denies contractions, loss of fluid, or vaginal bleeding and has had
positive fetal movement. Patient is alert and oriented at this time. Patient states that RUQ pain
started about 1.5 hours before coming to the hospital. This RN immediately calls for assistance. RN
attempts to find fetal heart tones. Difficulty tracing fetal heart tones due to patient condition. (See
doc flowsheet for heart tones) . Another RN at bedside attempting IV placement. Blood pressure
obtained, see vitals. Both RN's attempt IV placement, this is also difficult due to patient condition.
MD called to bedside for evaluation. At this time patient not in control, thrashing about the bed. 4
RNs and Trevor attempting to calm and reassure patient. IV obtained, labs drawn and
betamethasone given. MD remains at bedside. Multiple attempts made to obtain a blood pressure.
At approximately 1902 patient starts to seize. Patient is rolled to right side, suction performed, O2
applied via non-re-breather face mask at 10L/min. Staff OB at bedside and anesthesia paged
911. Magnesium Sulfate started at 4 grams over 30 minutes. Magnesium Sulfate not scanned into
MAR due to emergency. Magnesium administration confirmed with 5 RN's and MD. Airway and
patient safety maintained. Seizure lasts about 40 seconds. Anesthesia at bedside and is updated
on patients condition. Patient combative and unaware of her surroundings. RNs and _____attempt
to calm and reassure patient. Hydralazine 20mg given IVP. At the same time, another RN
attempting to find heart tones. Oxygen remains in place. Once fetal heart tones obtained, it
appears heart tones are in the 60s-70s, ultrasound at bedside to confirm. Fetal heart tones unclear
with ultrasound as well due to patient thrashing and uncooperativeness. MDs and RNs remain at
bedside attempting to monitor fetal heart tones with EFM and bedside ultrasound. Decision made
by MDs to stay in room until fetal heart tones are stable. Clear heart tones obtained at 1922, fetal
heart tones around 135 with minimal variability. At this time patient is calm and resting comfortably
but remains disoriented. At 1925 patient has another seizure that lasts for 75 seconds. Patient
rolled to right side, suction performed and oxygen reapplied due to patient taking off. After
seizure was complete, decision made to go to the OR for a cesarean section for delivery. This plan
discussed and confirmed with_____, he consents verbally for the patient (prior to first seizure
patient had verbally consented to treatment of care). 4 RNs and MDs wheeled patient to OR where
anesthesia and other RNs awaited. See intraop documentation for further care.
Primary LTCS delivery of 1026 gm male infant Apgars 1,7. Cord gases 6.92 arterial and 6.91
venous. EBL 1000.

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James is a longstanding patient at your surgery, he is 47-years-old and was

Paul is a 52-year-old self-employed builder who has diabetes. He presents to his GP

A 51-year-old female with a history of bipolar disorder presented to the ER claiming

CHIEF COMPLAINT: Cough and fever for four days

PHYSICAL EXAMINATION: The patient is an elderly man who appears tired

LABORATORY: WBC 17,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.

Mrs Kathleen Davis is a 77-year-old woman diagnosed with Metastatic Endometrial

The School would enter Kylie on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

To manage Ella’s risk on a daily basis the school has:

The School would enter Ella on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

To assist Eddy the school:

 utilises a slope board with a clip to steady paper when writing/drawing;

The School would enter Eddy on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

The key strategies the school is using to support Billy include:

 a small group intervention program for literacy;

The School would enter Billy on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

To support the boys to access the curriculum the teacher:

The School would enter Jayden on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

The School would enter Connor on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

The School would enter John on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

To assist Aaron in managing his behaviour the school:

 has implemented ‘Stop, Think, Do’ strategies;

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

Joseph is a Year 2 child with a diagnosis of dysgraphia. He has a history of attending

To support Joseph his teacher ensures he:

As a result of his teacher’s strategies, Joseph is progressing well and maintaining

confidence in his abilities.

The School would enter Joseph on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

Currently, the strategies in place to support Charlotte include:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

Key learning outcomes for Flynn include:

The School would enter Flynn on the Census as:

Category of Disability: ___________________________________________

Tara is a Year 11 student enrolled at a large metropolitan secondary education support

To support her current work placement Tara’s program includes:

 ASDAN Work Right Program;

The School would enter Tara on the Census as:

Category of Disability: ___________________________________________

The School would enter Andrew on the Census as:

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

Category of Disability: ___________________________________________

Level of Adjustment: ___________________________________________

To cater for Zac’s needs: