Bethune Best ONLY #3
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Running head: SMITH TREATMENT PLAN |
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SMITH TREATMENT PLAN |
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Case History Treatment Plan:
Sally Smith
Student Name
School
Case History for Treatment Plan
Report Regarding Sally Smith
Name: Sally Smith
SS#: 000-00-0000
Age: 42 years old
Date of Examination: 9/1/2016
Examiners: Fred Looney, PhD
Chief Complaint: Mental functioning
Sources of Information
Clinical Interview with Sally Smith
Medical Records
Brief Mental Status Examination
Wechsler Adult Intelligence Scale-IV (WAIS-IV)
Background Information
Ms. Smith is a 42-year-old African American female. She currently lives with her mother. She states she has one adult son from a prior marriage. Ms. Smith states she has a 2-year nursing degree and was employed as a nurse until 2015. She indicates that she does not attend church currently, but her mother attends on a weekly basis. As a child, she attended Sunday school and church periodically.
Ms. Smith states that she has been unable to work as a nurse due to medical problems. She reported that for years she had problems with high blood pressure, and, one day, she passed out and was put on a respirator. With further questioning, she reports that, on the day of this hospitalization, she drank an alcoholic beverage that reportedly was laced with “some drug.” Her medical records show a positive drug screen of benzodiazepines. The medical records state she was “brought in a comatose state” and was intubated.
The doctor’s records state that Ms. Smith had told him she had been taking OxyContin for pain and had gone to lunch with friends and had two drinks. When asked about the information in the medical records, Ms. Smith admitted to some problematic drinking during a one-year time frame. However, her reported history and the medical records do not coincide. Medical records report a diagnosis of alcohol poisoning.
Her medical history includes inflammatory bowel disease, acute gastritis, atypical chest pain, hypertension, and a history of alcohol abuse with elevated alcohol levels during admission. Ms. Smith states she has a history of depression and was admitted to a state hospital in 2016 due to suicidal ideations. She states her abusive alcoholic drinking is related to her depression. She does admit to consuming a “small” bottle of vodka on a daily basis at the height of her drinking. She denies any current alcohol use and is reportedly under the care of a doctor. She states her current diagnosis is bipolar disorder. She reports that she hears voices in her head and, at times, verbally responds to them. Ms. Smith was not able to list the medications she is currently on, nor are there any recent medical records as to her current medical conditions. Most recent record is January 2016.
Mental Status and Behavioral Observations
Attitude and Behavior: Ms. Smith was friendly and cooperative throughout the interview. She appeared to respond in a genuine manner when asked questions. At times, however, she appeared to be confused with the information requested of her. Her speech was slurred at times, and she had a glazed look about her.
Appearance: Ms. Smith appeared neat but casually dressed. She seemed to show adequate attention to her grooming needs. Ms. Smith did appear to have a slight odor, seemingly of alcohol.
Quality of Thinking: Ms. Smith’s thinking appears pressured and unorganized. Her reported history does not follow written reports; however, she does not appear to understand the inconsistencies. Her self-report appears to be what she believes to be her honest answer.
Abstraction Skills: Ms. Smith’s abstract thinking appears very limited; she was unable to explain how work and play are similar or why people are put on parole.
Affect and Mood: Ms. Smith appeared docile and cooperative throughout interview. However, the examiner continually needed to redirect her and help keep her focused.
Orientation: Ms. Smith was oriented x’s 3.
Memory: Ms. Smith’s memory appears limited as evident in her ability to only repeat 4 numbers forward and 3 backwards.
Attention and Concentration: Ms. Smith appeared to attend to all tasks at hand.
Judgment and Insight: Ms. Smith’s judgment and insight appear limited in her inability to follow logical order and recognize inconsistencies.
Intellectual Functioning Testing Results and Interpretations
Wechsler Adult Intelligence Scale-IV (WAIS-IV)
WAIS–IV Scale Score
Verbal Comprehension 67 (Extremely Low)
Perceptual Reasoning 73 (Borderline)
Working Memory 73 (Borderline)
Processing Speed 100 (Average)
Full Scale 67 (Extremely Low)
General Ability 99 (Average)
Ms. Smith is functioning in the Extremely Low range of intellect, with her Verbal Comprehension Index score significantly, but not rarely, lower than her Working Memory and Processing Speed. In addition, her current functioning is inconsistent with reported prior achievement and functioning.
Diagnostic Report and Treatment Planning
SUD Screening Results
SUD Assessment Results
Diagnostic Impressions
Diagnosis
Recommendations
BPSS Assessment
Bio-Psycho-Social-Spiritual Assessment
Family History – Current Family:
Family History – Family of Origin:
Vocational/Educational/Financial History:
Military History:
Legal Assessment:
Social/Leisure Assessment:
Spiritual/Cultural History:
Psychological Assessment:
Sexual History and Orientation:
Problem Areas:
Problem #1:
Problem #2:
Problem #3:
Problem #4:
Problem #5:
BPSS Summary
Identifying Information, Name, Marital Status, Residence, Employment, Referral, Family Situation, Reason for entering treatment, Alcohol/Drug History, Medical Assessment, Mental Status, Psychological Summary, Relapse Issues, Problem Areas: (additional?)
Treatment Plan (Problems 1-5) DO NOT COMPLETE! I WILL TAKE CARE OF THIS SECTION
PROBLEM #1:
GOAL:
Intervention:
1A.
1B.
1C.
PROBLEM #2:
GOAL:
Intervention:
2A.
2B.
2C.
PROBLEM #3:
GOAL:
Intervention:
3A
3B.
3C.
PROBLEM #4:
GOAL:
Intervention:
4A
4B.
4C.
PROBLEM #5:
GOAL:
Intervention:
5A
5B.
5C.
Conclusion
References Clinton, T., & Scalise, E. (2013). The quick-reference guide to addictions and recovery counseling: 40 topics, spiritual insights, and easy-to-use action steps. Grand Rapids, MI: Baker Books. ISBN: 9780801072321. Doweiko, H. E. (2015). Concepts of chemical dependency (9th ed.). Stamford, CT: Cengage. ISBN: 9781285148694. Hester, R. K., & Miller, W. R. (2003). Handbook of alcoholism treatment approaches (3rd ed.). New York, NY: Allyn & Bacon. ISBN: 9780205360642. Perkinson, R., Jongsma, A., & Bruce, T. J. (2014). The addiction treatment planner (5th ed.). Hoboken, NJ: Wiley. ISBN: 9781118414750.