Due Friday 10/18/2019

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

This section presents Ms. Smith’s diagnostic report and treatment plan. The report is based on the current information collected about her from a clinical interview conducted, medical records available, a brief mental status assessment and the Wechsler Adult Intelligence Scale-IV (WAIS-IV). The following is revealed:

Ms. Smith’s medical issues began during her spell as a nurse. She reports that her medical problems led to her terminating a nurse career she had prior to 2015. Her main problems were associated with high blood pressure for years. She also confesses to drinking an alcoholic drink laced with a certain drug. The following is a summary of her SUD screening results and assessment.

SUD Screening Results

Her SUD screen results indicate a positive drug screen of benzodiazepines. Her medical history also indicates that she had hypertension, atypical chest pain, inflammatory bowel disease, acute gastritis as well as alcohol poisoning. Besides having a history of depression, Ms. Smith also indicates she had a drinking problem for one year. She indicates that these two were highly related and whenever she feels depressed she would look for a “small” bottle of vodka. She reports that she currently does not take any alcohol.

SUD Assessment Results

Ms. Smith admits having had a drinking problem for a year. During her peak times, she would drink vodka, in what she described as small amounts. She also agreed to have been taking OxyContin for pain. Her medical history records also indicate that she had been diagnosed with alcohol poisoning.

Diagnostic Impressions

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

291.2 F10.27 Moderate or Severe Alcohol Use Disorder with Alcohol-Induced Major Neurocognitive Disorder, Nonamnestic-Confabulatory Type

305.50 F11.10 Opioid Use Disorder, Mild

307.89 F54 Psychological Factors Affecting Other Medical Conditions

296.80 F31.9 Unspecified Bipolar and Related Disorder

293.82 F06.0 Psychotic Disorder Due to Another Medical Condition with Hallucinations

V62.89 265.8 Religious or Spiritual Problem

Recommendations

Based on the above, therefore, the following recommendations are deemed necessary

· A thorough medical history should be created, based on the story she has told as well as her medical history. There is need to marry these two so that they speak the same language.

· Ms. Smith’s mental and behavioral assessment suggests that she also needs to see a psychologist/psychiatrist who will help her get through her anxiety. This will also improve her cognitive thinking, further improving her abstraction and judgement skills.

· Ms. Smith should be taken through therapy to reduce the chances of relapse; given that she is likely an alcoholic. This is in line with the report she gave about dealing with an alcohol problem for over a year.

· Medically-Assisted Detoxication is recommended.

Bio-Psycho-Social-Spiritual Assessment

Family History – Current Family: She reported that she used to accompany her mother to Sunday school at a young age but stopped. She is 42 years old and currently lives with her mother. She also has a son.

Family History – Family of Origin: Ms. Smith’s family has always been based on a strong Christian background. Her mother always attends church weekly, however, this is not true for Ms. Smith.

Vocational/Educational/Financial History: Ms. Smith reported that she had taken a 2-year bachelor’s degree course in Nursing and had served as a nurse till 2015. However, her family does not seem to have any financial issues. The fact that she was taken to school indicates that they might have been in a good financial position.

Military History: Ms. Smith does not report any military history.

Legal Assessment: Ms. Smith does not report any legal history. This may point that she is a law-abiding citizen.

Social/Leisure Assessment: Ms. Smith is a social person and enjoys having lunch and taking drinks with her friends. Her attitude and behavior are also friendly and cooperative.

Spiritual/Cultural History: Ms. Smith’s mother is a staunch Christian who attends church at least once every week. While Ms. Smith herself used to attend church periodically, she no longer attends church as often as she should.

Psychological Assessment: Ms. Smith’s psychological assessment is based on the facts reported from observing her mental status and behavior. Her attitude and behavior indicate that she is friendly, honest and cooperative. Her flow of thought, however, indicated that she is tense and appears to be under pressure all the time, making her judgement questionable. Her abstraction skills are somewhat limited, so is her memory. It is important to note that she is attentive, meaning that her levels of concentration are high.

Sexual History and Orientation: Ms. Smith was married, has a son, meaning that her sexual orientation is heterosexual. She is currently single.

Problem Areas

Problem #1: Substance Use

Problem #2: Chronic Pain/Medical Issues

Problem #3: Bipolar Disorder

Problem #4: Treatment Resistance

Problem #5: Relapse Proneness

BPSS Summary

Name: Sally Smith

Marital Status: Single

Residence: N/A

Employment: Unemployed (Former Nurse)

Family Situation: She has a son from a previous marriage and currently lives with her mother.

Reason for entering treatment: Mental functioning

Alcohol/Drug History: She used to drink a “small” bottle of vodka. Was once diagnosed with alcohol poisoning

Medical Assessment: Medical history indicates she had inflammatory bowel disease, acute gastritis, atypical chest pain, hypertension, and a history of alcohol abuse Mental Status: Based on the Wechsler Adult Intelligence Scale-IV (WAIS-IV) IQ test results, results, Ms. Smith’s verbal comprehension is extremely low. Her perceptual reasoning and working memory are on the borderline while her processing speed and full-scale scores are average and extremely low respectively. Her general mental ability is therefore described as average. Psychological Summary: Her attitude and behavior indicates that she is friendly, honest and cooperative. Her flow of thought, however, indicated that she is tense and appears to be under pressure all the time, making her judgement questionable. Relapse Issues: Ms. Smith reports that she is not currently utilizing substances to cope with her mental and medical issues. However, her labs and affect report otherwise.

Treatment Plan (Problems 1-5)

PROBLEM #1: Substance Use Disorder

GOAL: Establish a sustained recovery, free from the use of all mood-altering substances (Perkinson, Arthur, & Bruce, 2014).

Objective 1: Provide honest and complete information from a chemical dependence biopsychosocial history (Perkinson, Arthur, & Bruce, 2014).

Intervention 1: Gather a complete drug/alcohol history from the client, including the amount and pattern of her use (Perkinson, Arthur, & Bruce, 2014).

Objective 2: Participate in a medical evaluation to assess the effects of chemical dependence (Perkinson, Arthur, & Bruce, 2014).

Intervention 2: Refer the client for an examination to determine consequences of substance use (Perkinson, Arthur, & Bruce, 2014).

Objective 2: Cooperate with an evaluation by a physician for psychotropic medication (Perkinson, Arthur, & Bruce, 2014).

Intervention 2: Assess the need for psychotropic medication for any mental/emotional comorbidities (Perkinson, Arthur, & Bruce, 2014).

PROBLEM #2: Chronic Pain

GOAL: Regulate pain without addictive medications (Perkinson, Arthur, & Bruce, 2014).

Objective 1: Describe the nature, history, and impact of chronic pain, medical issues, and substance abuse (Perkinson, Arthur, & Bruce, 2014).

Intervention 1: Assess the manifestation of chronic pain/medical issues, its history, triggers, and methods of coping (Perkinson, Arthur, & Bruce, 2014).

Objective 2: Cooperate with a thorough medical examination to rule out any alternative causes for pain and explore treatment options (Perkinson, Arthur, & Bruce, 2014).

Intervention 2: Refer the client to a physician to undergo an examination.

Objective 3: Follow through with pain management (Perkinson, Arthur, & Bruce, 2014).

Intervention 3: Discuss cautious-use of medications to manage pain (Perkinson, Arthur, & Bruce, 2014).

PROBLEM #3: Bipolar Disorder

GOAL: Alleviate mood symptoms and return to previous level of effective functioning (Perkinson, Arthur, & Bruce, 2014).

Objective 1: Describe the personal history of mood changes and associated changes in behavior (Perkinson, Arthur, & Bruce, 2014).

Intervention 1: Encourage client to share her thoughts and feelings, express empathy, and build rapport while assessing symptoms of the mood disorder (Perkinson, Arthur, & Bruce, 2014).

Objective 2: Identify depressive behavior patterns and list several instances in which it led to addiction (Perkinson, Arthur, & Bruce, 2014).

Intervention 2: Assess the client’s addictive behavior history (Perkinson, Arthur, & Bruce, 2014).

Objective 3: Turn over at least one problem to a higher power each day (Perkinson, Arthur, & Bruce, 2014).

Intervention 3: Assign the client to turn over one problem each day to a higher power (Perkinson, Arthur, & Bruce, 2014).

PROBLEM #4: Treatment Resistance

GOAL: Accept the powerlessness and unmanageability that addiction has brought to life, and actively engage in the treatment process (Perkinson, Arthur, & Bruce, 2014).

Objective 1: Share the feelings that surround admission to treatment (Perkinson, Arthur, & Bruce, 2014).

Intervention 1: Probe the reasons why the client is resisting treatment (Perkinson, Arthur, & Bruce, 2014).

Objective 2: Cooperate with biopsychosocial assessment and accept the treatment recommendations (Perkinson, Arthur, & Bruce, 2014).

Intervention 2: Share the results of the assessment, medical labs, and recommendations with client (Perkinson, Arthur, & Bruce, 2014).

Objective 3: Provide data for a Stage of Change assessment (Perkinson, Arthur, & Bruce, 2014).

Intervention 3: Assess client’s position in the Stage of Change (Perkinson, Arthur, & Bruce, 2014).

PROBLEM #5: Relapse Proneness

GOAL: Maintain freedom from addiction without experiencing relapse (Perkinson, Arthur, & Bruce, 2014).

Objective 1: Write a detailed chemical use history, describing treatment attempts and the specific situations surrounding relapse (Perkinson, Arthur, & Bruce, 2014).

Intervention 1: Assign the client to write a chemical use history, describing her attempts at recovery and the situations surrounding relapse (Perkinson, Arthur, & Bruce, 2014).

Objective 2: Verbalize the powerlessness and unmanageability that result from addiction and relapse (Perkinson, Arthur, & Bruce, 2014).

Intervention 2: Help the client see the powerlessness and unmanageability that result addiction and relapse using a 12-step recovery program’s Step 1 exercise (Perkinson, Arthur, & Bruce, 2014).

Objective 3: Verbalize that continued alcohol/drug abuse meets the 12-step program concept of insanity (Perkinson, Arthur, & Bruce, 2014).

Intervention 3: Using a 12-step recovery program’s Step 2 exercise, help the client to see the insanity of her disease (Perkinson, Arthur, & Bruce, 2014).

Conclusion

Patients with Substance Use Disorder often require therapy ranging from different aspects. However, before giving it to them, there is need to conduct a thorough diagnosis of the patient to ascertain their status. Sally Smith’s case is a perfect example of how half-done diagnostics can result to an escalation of the problem rather than solving it. Prior to the information provided in this diagnostic report, Ms. Smith’s medical records does not coincide with her medical history. This, in most cases, makes it hard to conduct effective therapy that would cure such a patient.

Information needs to be collected from various sources as was the case in this report. Ms. Smith’s information was collected through Clinical Interviews, Medical Records, Brief Mental Status Examination and even the IQ-test for adults i.e. Wechsler Adult Intelligence Scale-IV (WAIS-IV). All these provided enough information to make the recommendations made for her to be taken through. The information indicated that she probably suffers from depression and alcoholism. She also has memory issues. She can thus get the help she needs from specific health care practitioners.

References 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.