Case study: Diagnosis and Treatment Recommendations

Case study: Diagnosis and Treatment Recommendations

Read the case study provided and write a clinical report which includes:
1. A summary of the major issues facing the client needing to be addressed.
2. A working diagnosis for the client (with diagnostic summary and rationale) utilizing the following information from the CAGE screening tool and case history information.
3. A Mental Status Exam which applies the information from the case history.
4. Detailed treatment recommendations determining which modality (family, individual, group, or couples) is most appropriate for this client. Be sure to provide the rational for your choice by integrating information from the case summary.
5. Recommendations on whether individual is a good candidate for treatment placement (inpatient, residential, or outpatient) and an analysis of the pros and cons for your selection based on a summary of the issues.

Case Information
Client: Joseph Blackwell
Date of Birth: July 10, 1961

Identifying Information
Gender: Male
Age: 49
Religion: Baptist
Race/Ethnicity: Caucasian
Disability: No visible disabilities
Class: Annual income under $12,000
Educational Qualification: High School Diploma

Current Family Constellation and Living Arrangements
Married currently separated
3 children, ages  20, 15, 2
Currently homeless, staying with a friend

Other Family Information
Mother gives money to him on a consistent basis
The only person who “nags” him about his drinking is his wife
Other family members have covered for him on more than one occasion, telling his wife he was working when he was really getting high.

Employment Status
Recently lost job due to failure to show up.
Employed there for 6 months
Reports having over 10 jobs in the last 5 years
Skilled as a roofer

Legal Problems
Took a Plea for Treatment in lieu of conviction for current possession of cocaine charge
License suspended for Driving Under the Influence
Currently on Probation

Past/Current Psychological Problems
Reports a diagnosis of Bipolar Manic Depression made several years ago
States “I just wants it all go away, maybe it be better if I just went away, sometimes I cry when I wake up.”

Medication history
Records indicated that the client has been treated off and on with Seroquel and Lithium. He reported that both medications helped him feel more “calm and collected.” He has been off of medication for the past 2 months.

Substance Use history
The client stated that he drinks alcohol every day, usually 1 liter of vodka and a few beers.  This pattern of drinking endured for the past 10 years. He tried to stop drinking one time and the longest that he has abstained from drugs and alcohol was for a period of 3 months a few years ago. He also uses cocaine and marijuana several times per week.  He stated that he has thought about stopping the substance use, but is sure that he will never be able to abstain. The patient has a history of the shakes when he has attempted to stop drinking in the past. He has tried outpatient substance abuse counseling, though would usually relapse after a few sessions. He has never participated in inpatient detox.

Records reviewed (Psychiatric ER summary dated August 6, 2010)
Patient was admitted to the X psychiatric emergency room and placed on a 72 hour observation. He was brought in by emergency medical services and a police escort after he was found in the street yelling that he wanted to die and threatening bystanders at the local bus station.  His toxicology screening was positive for alcohol, marijuana, cocaine, and benzodiazepines.  After the 72 hour observation the substances had cleared, the patient was administered Librium for alcohol withdrawal complications, and by day 3 he denied suicidal, as well as homicidal ideation. Thus, he was released, in good behavioral control, and referred to an outpatient chemical dependency program. Records indicated that the pt has a diagnostic history that includes, Bipolar Disorder Not Otherwise Specified, Alcohol Dependence, and Polysubstance Abuse.

Last  evaluation: Wednesday, March 9, 2011
Client presented wearing a t-shirt stained with food and smelling of beer. His jeans were tattered with random holes and burn marks. His hair was long and tangled. He was malodorous. The client required multiple redirections to lower his voice and to get him back on topic as he kept changing the topic to discuss unrelated content, such as food that he wanted to eat and about a new pair of shoes that he hoped to buy. The client’s mood was unstable in that he vacillated between irritable, depressed, and euphoric states during this interview. He avoided eye contact and moving around in his chair often. He often laughed when discussing his most recent DUI and when discussing that he lost his most recent job. Client knew that he was at Agency X for a psychological evaluation, stated that it was Tuesday and that the year is 2010. He sleeps, at times, 3-4 hours per night, and sometimes does not feel the need to sleep at all. Client denied hearing voices, seeing things that others cannot, and is not paranoid. He denied any desire or plan to hurt other people. He admitted one suicide attempt by taking pain pills that were washed down with 1 liter of vodka last year because he wanted to “escape.” The client often ponders what it would be like to not be alive anymore and reported that he thought about taking a bottle of pain medication this morning in an effort to attempt suicide.

CAGE Screening Tools answers from client:
1.     Have you ever felt you should “cut down” on your drinking?
Answer:   Yes, I have tried on several occasions to drink less.  The last time I tried was about 2 years ago.
2.     Have people “annoyed” you by criticizing your drinking?
Answer:  That is why I left my wife.  All she did was nag about what and when I drink.  I got sick of it.
3.     Have you ever felt bad or guilty about your drinking?
Answer:   Kind of sort of…
4.    Did you ever take an “eye opener” a drink first thing in the morning to steady your nerves or get rid of a hangover?
Answer:   Doesn’t everyone do this every once in a while.  It takes the edge off with everything I have going on.

Case study: Diagnosis and Treatment Recommendations

Case study: Diagnosis and Treatment Recommendations

Read the case study provided and write a clinical report which includes:
1. A summary of the major issues facing the client needing to be addressed.
2. A working diagnosis for the client (with diagnostic summary and rationale) utilizing the following information from the CAGE screening tool and case history information.
3. A Mental Status Exam which applies the information from the case history.
4. Detailed treatment recommendations determining which modality (family, individual, group, or couples) is most appropriate for this client. Be sure to provide the rational for your choice by integrating information from the case summary.
5. Recommendations on whether individual is a good candidate for treatment placement (inpatient, residential, or outpatient) and an analysis of the pros and cons for your selection based on a summary of the issues.

Case Information
Client: Joseph Blackwell
Date of Birth: July 10, 1961

Identifying Information
Gender: Male
Age: 49
Religion: Baptist
Race/Ethnicity: Caucasian
Disability: No visible disabilities
Class: Annual income under $12,000
Educational Qualification: High School Diploma

Current Family Constellation and Living Arrangements
Married currently separated
3 children, ages  20, 15, 2
Currently homeless, staying with a friend

Other Family Information
Mother gives money to him on a consistent basis
The only person who “nags” him about his drinking is his wife
Other family members have covered for him on more than one occasion, telling his wife he was working when he was really getting high.

Employment Status
Recently lost job due to failure to show up.
Employed there for 6 months
Reports having over 10 jobs in the last 5 years
Skilled as a roofer

Legal Problems
Took a Plea for Treatment in lieu of conviction for current possession of cocaine charge
License suspended for Driving Under the Influence
Currently on Probation

Past/Current Psychological Problems
Reports a diagnosis of Bipolar Manic Depression made several years ago
States “I just wants it all go away, maybe it be better if I just went away, sometimes I cry when I wake up.”

Medication history
Records indicated that the client has been treated off and on with Seroquel and Lithium. He reported that both medications helped him feel more “calm and collected.” He has been off of medication for the past 2 months.

Substance Use history
The client stated that he drinks alcohol every day, usually 1 liter of vodka and a few beers.  This pattern of drinking endured for the past 10 years. He tried to stop drinking one time and the longest that he has abstained from drugs and alcohol was for a period of 3 months a few years ago. He also uses cocaine and marijuana several times per week.  He stated that he has thought about stopping the substance use, but is sure that he will never be able to abstain. The patient has a history of the shakes when he has attempted to stop drinking in the past. He has tried outpatient substance abuse counseling, though would usually relapse after a few sessions. He has never participated in inpatient detox.

Records reviewed (Psychiatric ER summary dated August 6, 2010)
Patient was admitted to the X psychiatric emergency room and placed on a 72 hour observation. He was brought in by emergency medical services and a police escort after he was found in the street yelling that he wanted to die and threatening bystanders at the local bus station.  His toxicology screening was positive for alcohol, marijuana, cocaine, and benzodiazepines.  After the 72 hour observation the substances had cleared, the patient was administered Librium for alcohol withdrawal complications, and by day 3 he denied suicidal, as well as homicidal ideation. Thus, he was released, in good behavioral control, and referred to an outpatient chemical dependency program. Records indicated that the pt has a diagnostic history that includes, Bipolar Disorder Not Otherwise Specified, Alcohol Dependence, and Polysubstance Abuse.

Last  evaluation: Wednesday, March 9, 2011
Client presented wearing a t-shirt stained with food and smelling of beer. His jeans were tattered with random holes and burn marks. His hair was long and tangled. He was malodorous. The client required multiple redirections to lower his voice and to get him back on topic as he kept changing the topic to discuss unrelated content, such as food that he wanted to eat and about a new pair of shoes that he hoped to buy. The client’s mood was unstable in that he vacillated between irritable, depressed, and euphoric states during this interview. He avoided eye contact and moving around in his chair often. He often laughed when discussing his most recent DUI and when discussing that he lost his most recent job. Client knew that he was at Agency X for a psychological evaluation, stated that it was Tuesday and that the year is 2010. He sleeps, at times, 3-4 hours per night, and sometimes does not feel the need to sleep at all. Client denied hearing voices, seeing things that others cannot, and is not paranoid. He denied any desire or plan to hurt other people. He admitted one suicide attempt by taking pain pills that were washed down with 1 liter of vodka last year because he wanted to “escape.” The client often ponders what it would be like to not be alive anymore and reported that he thought about taking a bottle of pain medication this morning in an effort to attempt suicide.

CAGE Screening Tools answers from client:
1.     Have you ever felt you should “cut down” on your drinking?
Answer:   Yes, I have tried on several occasions to drink less.  The last time I tried was about 2 years ago.
2.     Have people “annoyed” you by criticizing your drinking?
Answer:  That is why I left my wife.  All she did was nag about what and when I drink.  I got sick of it.
3.     Have you ever felt bad or guilty about your drinking?
Answer:   Kind of sort of…
4.    Did you ever take an “eye opener” a drink first thing in the morning to steady your nerves or get rid of a hangover?
Answer:   Doesn’t everyone do this every once in a while.  It takes the edge off with everything I have going on.