Bethune Best ONLY #3

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.

Screening and Assessment Results Regarding Substance Use

Start your assignment with this section. Do so in current APA format, providing proper citations. There is no need to include the details above this in your assignment. If you were the person who conducted the screening and assessment, what other measures would you use? Explain the measures you would use and why, as well as what different scores would indicate for this client. Consider what you have written for the Screening/Assessment Essay. Also, consider the levels of headings you will be using, since you are starting with this section. The title of your paper will be your first heading.

Diagnostic Impression

In this section, you must provide the evidence for the diagnosis/diagnoses you provide below, making sure to consider the criteria needed for the diagnosis/diagnoses you assign. Remember: You have access to the DSM-5 through the library website.

Diagnoses

List the diagnosis/diagnoses here by utilizing the DSM-5. Note that you should have enough detail in Doweiko (2015), but you also have access to the DSM-5 through the library website.

Treatment Plan for Sally Smith

Utilizing (and properly citing/quoting) Perkinson, Jongsma, and Bruce (2014) as well as other course resources, create your treatment plan here. Make sure to include a conclusion at the end of your assignment as well as references. Incorporate recommendations regarding spirituality/faith in your treatment plan.

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