Trauma Case Study
Reason for Referral
Maryam is a 17-year-old Caucasian female university student who was referred to your agency by her physician Dr. Jaffee. Maryam presented in her doctor’s office complaining of lack of sleep. Dr. Jaffee did not give her medication as Maryam has reported drinking three to four glasses of vodka and orange juice per night to sleep. Dr. Jaffee’s report indicates the patient is sleeping 2-4 hours per night and often awakens with nightmares. Blood tests were normal with the exception of slightly elevated liver enzymes. Blood pressure was 130/94. Patient was scheduled for a follow-up appointment in two weeks.
Maryam arrived on time for her appointment. She was driven to the appointment by her university roommate. The client appeared anxious, had circles under her eyes, and was tearful during the intake. Maryam was oriented to time, place, and person. Client vocabulary was above average. Client appeared tired and despondent evidenced by low voice, soft speech, and flat affect.
Maryam states “I can’t drive a car. I am too afraid that someone will hit me or I will hit someone else. I can’t sleep so I don’t get up to go to class in the morning.” Client states, “I am afraid to drive.” She goes on to state, “I made such a horrible mistake; I don’t deserve to live. I am so stupid.”
Client states that she was involved in a three car accident two months ago. Client reports one person was critically injured and the other was treated and released at the hospital. Client reports she received a citation, as she turned in front of two oncoming cars at a red light.
Client reports that she lives in student housing on the campus of a local university. She has one roommate who brought her to today’s appointment.
Legal: Client is facing legal problems due to the accident.
Family Support: Maryam’s family lives out of state. She has no relatives that live locally.