Biopsychosocial Case Practice “Peer-Review

Biopsychosocial Assessment Outline for SW660 (revised January 2022)

Please use the same headings to divide the content but do not use the letters in the details of the outline; rather, write the information in a narrative (sentence) format.

The following areas must be addressed in the assessment. 

1. Demographic Data

Date: 12/3/2021

Name: J. Jacobs

Age: 27

Sex: Male

Race: Indian

Source of income: Business

Marital Status: Single

Living arrangements: Lives alone but has friends around the area he is in.

2. Presenting Problem

The patient was having different symptoms. He complained on him be easily irritated, they get to be more overwhelmed and nothing is making them happy around them and they tend to feel sad more and more. He had some impulsivity of most. He is a t a high risk of getting depressed.

2. Family History

E is the only child of a broken family. His parents divorced when he was still young and was raised by a single mum who was irresponsible and was much drunk. His extended family also separated when the marriage failed. All is life it has just been him and his mother who was at some point violent and always absent when it come. He was in a relationship with a girl who left and broke his life and through that he met many more ladies he slept with and left. He had many friends that have been loyal.

3.  Education and Work History/Military

Jacobs is not working in any place that is because he was recently fired from his work place because he was reckless and irresponsible. He was educated and had gone through school to study sales and marketing though he is not interested in practicing it.

4.  Psychiatric and Medical History

While in high school he was abusing marijuana and was taken to rehab center and a therapy session.

5.  Substance Use History

He has a history of abuse of marijuana. He currently using cigarettes, marijuana and alcohol.

6. General Observations and Mental Status:

A. Appearance, grooming/hygiene, size/weight, is clothing appropriate to the weather/setting- he looked very careless and dirty in the clothing and the body state that he was in.

B. Ability to participate/Effort made/Motivation- he was inactive in most of the things and activities that he was partaking in

C. Orientation (who, what, where, day, date, time)-

D. Cooperation/Attitude- e had a negative attitude and he didn’t love everything around him

E. Attention, posture, Eye Contact, psychomotor agitation or retardation- he looked dehydrated in his eye

F. Speech (rate, tone, volume, content, fluidity, accent)- staggering, vulgar speech that was delivered slowly in a loud voice

G. Affect and its congruence with mood- just in a short time John with provoked with the tinniest things.

H. Mood (as they describe it and your assessment) – somber mood

I. Memory (does it appear intact, did you do memory test, obvious problems? Consider short and long-term)- he has a short term memory and forgets things easily.

J. Thought Process (logical, linear, tangential, circumstantial, etc) - circumstantial

K. Thought Content (bizarre, typical, appropriate to the setting and situation, etc)- typical

L. Perceptual Disturbances, hallucinations, loss of rational thinking, suicidal/homicidal- he has experienced a lot of hallucinations

M. Judgment- addicted and was experiencing the process addiction.

N. Insight- depression

7. Clinical Impressions (theories with rationale)

The patient looked more depressed and dependent on arrival. He was dehydrated and malnutritioned. He was underweight and looked sick.

8. Recommendations (interventions with rationale)

Rehabilitation center. Book therapy sessions that are relevant to the patient. Drugs that will help him on the developed conditions and reverse the psychological effects. Have all the plans to prevent illnesses and find the treatment plan in managing the pain. Try and reconnect him to his mother and give him a diet plan.

Three questions.

How do you create a safe space so that you can get all the information that will aid and help in patient’s diagnosis?

What are the considerations that should be put in place when prescribing treatment plan for the above patient?

What is the intervention that will help the patient to attend all their assigned therapy sessions?