Mr Trotter Case Study

Mr. Goins is a 52 year old male who presented to the ED via LEO following a 4 day binge on alcohol and requesting help with his dependence. Mr. Goins reports he moved to Asheboro recently and found work, however recently lost his job. He reported a history of alcohol use and depression. Dr. Keith requested an assessment on Mr. Goins.At the time of the assessment Mr. Goins denies suicidal ideation, homicidal ideation, and symptoms of psychosis. He reports 5 days ago he became unemployed. Mr. Goins reports his fiance who is his primary support system left town to go to a doctor appointment in their home state of Georgia. He reports binge drinking for the past 4 days attempting to cope with his recent stressor. Mr. Goins reports calling his fiance last night an expressed to her he need help. He states, "I told her I felt at the time no reason to live." Further Mr. Goins stated, "I just had too much in me last night, I had about 14 of them airplane bottles." Mr. Goins denies a history of self harm. He does report a prior hospitalization for depression in Georgia. He also reports a history of attending substance abuse treatment, which was a positive experience for him.

Freeman and M. Rapp spoke R. Morrison and Zachary together about how she things were going in the home. R. Morrison stated overall things were going well.  There are no concerns, that Zachary had his moments and overall  he was doing a fine job following house rules, and adjusting to living with his twin brother again.

S has quite a strong baseline of strengths. Firstly, Mrs. S is a very kind man, never lashing out during interviews, always receptive of health provider interventions even when he might not agree. In addition, he has completed his high school diploma. Mr. S is also good at maintaining and looking after his room at the booth, as evidenced by the recounts of the case manager’s room visit. In addition, Mr. S always attends his medical appointments, and IM injection appointments, and has good insight on their importance. The patient is also has insight to find help from the institute or ER if warning signs, or symptoms creep up. Mr. S is also responsible enough to call if he cannot make an appointment. In addition, he has good personal hygiene during his visits. Mr. S also has a number of deficits he has to combat. First of the deficits, include his ¬¬lack of social support; like previously mentioned about his parents, half-sister or half-brother. This can put Mr. S at risk for redevelopment of avolition and negative symptoms that have previously hindered his success, and will become deficits. Another deficit is his inability to manage his own finances and money, as he gets his welfare allowance every week from his case manager, and social worker, who also manages his finances. A third deficit might be his inability to get food. The final deficit, would be his situation with the Booth Center, as he might find himself to be homeless. Mr. S’ only resources are the case manager, the writer, social worker, and the FEPP

This recommendation is that Mr. Turner attend outpatient alcohol and other drug counseling to address his dependency and his depression. His alcohol and drug use is severe enough that outside help is warranted. Despite the consequences of his alcohol and other drug use, Turner is in denial and does not think he needs further professional

The client’s primary care physician is Dr. Damian Covington. The client does not currently have a psychiatrist.

PO had no service plan open in this dimension due to participating only one week in treatment. PO reported that he is living with his fiancé and her children at this time. PO reported he is not working due to working increased a level of stress and anxiety into his daily life. PO reported attending AA meeting and communicating with his sponsor regularly. PO will benefit from building and utilizing positive

has become more financially stable during the last quarter. Pt. reported some financial struggles but he recently found a new full-time job. Pt. has done well in achieving his goal of maintaining financial compliance with all treatment fees over the last quarter. Pt. always maintains a positive balance in his AMS account. Pt. reported that he needs to pay several traffic tickets to obtain his driver license. Counselor will encourage Pt. to report any negative financial changes to his AMS Primary Counselor and/or AMS Director as soon as

Mr. Lucas was diagnosed with Axis I: major depression, recur, severe wo/ psych/ mother passed away at age 5. Axis II Active- Chronic pain specified manifestations; major depression disordered, single, mild wo/psych and antisocial personality disorder, recurrent; chronic pain due to nerve damage from being shot. Type III. Axis IV: Economical problems, problems, Problems with primary support group and problems related to social environment and other psychosocial and environmental problems. According to the Developmental Center psychiatric evaluation level of care/care recommendation is HIGH intensity community base services. It states Mr. Lucas may need substance abuse treatment, individual therapy, case management, and care to with assist

D/A: Mr. Brown had three appointments this week. On 02/20/17, Mr. Brown was transported to his appointment with Dr. Walsh at 10:00 a.m. and went for his PET scan at the Women Center in Dover on 2/22//17. The Christiana Care Home Health Physical Therapist visited Mr. on 02/20/17, 02/22/17 and 02/24/17 at the Connections Still Road Group Home. On 02/22/17, Mr. Brown received physical therapy treatment in his bedroom, because he was too weak to come outside his room to receive treatment. According to the Physical Therapist notes dated 02/22/17, Mr. Brown tolerated treatment well with a rest period between activities due to complain of fatigue, neck & back pain rated 8/10 where ten is the most painful. Mr. Brown met with his Psychiatrist Dr. Capiro on 02/19/17. Dr. Capiro provided Mr. Brown a direct service at the Residential Program. The service

Client has been discharged from OP/TSF services under PBH due to the significant progress of his treatment goals. The client is current in the transition of being adopted was to receive services from another agency for OP therapy. Due to the different transition in the client life, it was recommend the client continues to receive OP therapy from New Behavioral Network to help him with his upon coming adoption in December 2016.

Dr. Straker has been in private practice on the Upper East Side of Manhattan for the past 12 years. He is an Attending Psychiatrist on staff at Columbia University Medical Center - NY Presbyterian Hospital, Lenox Hill Hospital, Long Island Jewish Medical Center and North Shore University Hospital. He also works in the Emergency Room and as a Consultation-Liaison Psychiatrist at White Plains Hospital.

CM received an email from Brooke Gottheimer (New Jersey Mentor – therapist) regarding Treshawn’s behaviors. CM was informed youth was involved in a fight at camp on Tuesday, 7/25/17 and ran away from the camp for about 15-20 mins. Treshawn came back to the camp and proceeded to use inappropriate language towards the staff members. Ms. Gottheimer noted Mrs. Thompson (New Jersey Mentor parent) will look into other camps that may still be available nearby. Ms. Gottheimer will continue to keep CM updated. CM informed Ms. Gottheimer that Treshawn’s has been approved for a Psychiatric Community Level of Care and provided the list of OOH treatment for youth. CM noted CM will contact the sites to schedule meet and greets.

Presenting Problem: This section should be a summary of the case, specifically focusing on why the client is seeking help, what his or her referral route to the counselor is, known symptoms, and possible diagnosis. Leo is a 90-year-old, heterosexual, white male with symptoms of substance use of tobacco, alcohol, depression and high anxiety. Leo was referred for counseling by his doctor because he has difficulties and the ability to care for himself.

After talking with Mr. Hamilton worker spoke with caseworker, Stephanie Spain. She stated that a mental consult with Senior Care was scheduled. However, he was not scheduled for discharge. If he refused service, mental consult would be cancelled. Worker recommended they have Dr. Osula speak with Mr. Hamilton because in the past Mr. Hamilton had worked well with Dr. Osula.

Phil came into the clinic because his wife had requested him to receive some professional help. While he was at the clinic, the meeting did not last long. He was there for about an hour and I was able to determine some psychological disorders that Phil may be suffering from. Phil was asked to come back in for follow-up sessions which he will be asked more questions and complete assessments that are the appropriate diagnosis of Phil.