To prepare: Use a differential diagnosis process and analysis of the Mental Status Exam in the case provided by your instructor to determine if the case meets the criteria for a clinical diagnosis.
CASE OF LUCIA
INTAKE DATE: January 2019
IDENTIFYING/DEMOGRAPHIC DATA: Lucia is a 53-years-old Hispanic female. She has two adult sons, aged 27 and 24, who both live with her. She works full time as an executive secretary. Lucia has a live in boyfriend, Tomaz. They have been together 8 years.
CHIEF COMPLAINT/PRESENTING PROBLEM: “I am in constant physical pain every day and can hardly walk and move. Even at night when I am in bed I am always in pain.” Lucia reports that even in the few moments the pain eases it is difficult for her to get sleep.
HISTORY OF PRESENT ILLNESS: Lucia has been suffering from physical pain for the past 18 months. She has been to many doctors for help. Lucia has been very concerned about her illness and wants to understand the causes of this pain. There has never been an accurate diagnosis. She has been given medication and steroids with no relief of her physical pain. Most recently, she had a full evaluation at the Mayo Clinical which had inconclusive results. One doctor at the Mayo clinic suggested she seek individual counseling, hoping this will help her physically as well. Lucia’s reports her anxiety is so high now with all the stress she is under.
PAST PSYCHIATRIC HISTORY: Lucia denies any past psychiatric history for herself. The only significant family history is her older brother’s diagnosis of Intellectual Disability.
SUBSTANCE USE HISTORY: Lucia reports drinking socially and very minimally. There is no evidence of substance use disorders in her family.
PAST MEDICAL HISTORY: Lucia has been ailing over the past 18 months with unidentified pain. There were no previous significant medical issues in her past.
FAMILY MEDICAL AND PSYCHIATRIC HISTORY: Lucia is the third child of four from her parents union. She has an older sister, a brother, and a younger sister. Her brother was diagnosed with intellectual disability from a young age. The family’s focus has always been on taking care of her older brother. Her father died 6 years ago. Lucia lost her mother to dementia 6 months earlier than this intake. With the death of her mother, the responsibility of her brother has now been transferred to Lucia and her two sisters. Lucia reports feeling responsible for her extended family and needs to be involved with their issues. She recalls growing up and always feeling not worthy to be part of the family. She is hoping that the family would value her more than she believes they do.
CURRENT FAMILY ISSUES AND DYNAMICS: Lucia divorced 17 years ago after 12 years of marriage. The marriage was tumultuous. Her husband was addicted to pornography and had several affairs. Lucia denies any physical abuse but reports a lot of emotional abuse that she sustained from her husband. Lucia maintained the family house after the divorce but had very little money to support the household and her two sons. Lucia’s financial issues continued to increase her stress over the years.
Eight years ago, Lucia began a romantic relationship with Tomaz after a long term work friendship. Tomaz divorced nine years ago. Lucia believed she was finally happy in a relationship. Tomaz moved into her home soon after their romantic relationship began. Tomaz promised he would take care of her financially for the rest of her life.
Four years ago, Tomaz was diagnosed with terminal cancer. Following the diagnosis, Tomaz became a spendthrift and purchased very large items such as trucks, motorcycles, and ATV’s. Lucia was feeling increased stress with the loss of her mother, the burden of care taking her brother, Tomaz’s diagnosis and his increased spending of his money. She always found herself fatigued due to this stress.
MENTAL STATUS EXAM: Lucia presented as a casually dressed, meticulously groomed woman who appeared her stated age of 53. She had a fixed, mood congruent expression on her face. Motor activity was normal. Mood appeared depressed and was dysphoric. Affect was constricted. Speech was guarded and soft, content wastake, Lucia’s thoughts would jump around. She noted that over the past several months she has had an inability to concentrate at work. Digit span was 7 forward and 4 in reverse. She was unable to calculate serial 7's. Recent and remote memory appeared intact. Intelligence appeared above average and fund of knowledge was excellent. All factual questions were answered correctly. Lucia was able to abstract similarities and proverbs with detail and accuracy. Ordinary social and personal judgment was appropriate. adequate. Thought processes were goal-directed, logical but at times distracted. There was no evidence of delusions. Lucia was oriented to time, place, and person. During the intake Lucia’s thoughts would jump around. She noted that over the past several months she has had an inability to concentrate at work. Digit span was 7 forward and 4 in reverse. She was unable to calculate serial 7's. Recent and remote memory appeared intact. Intelligence appeared above average and fund of knowledge was excellent. All factual questions were answered correctly. Lucia was able to abstract similarities and proverbs with detail and accuracy. Ordinary social and personal judgment was appropriate.
This is mostly left to the imagination. I didn’t actually participate in any projects so it is all based on the assignments. There was no remarks left by the professor so most of this will be based on fictitious activity with speculation on results.
Over the past several weeks, you have analyzed a policy related to a social problem and have advocated for change. This week you submit your final report and present on your experience and the outcomes of your Social Change Project.
To PrepareWrite up a final report of your Social Change Project.
The final report should include your compiled response to assignments from Weeks 3, 8, and 9. You are expected to update and revise the papers based on your instructor’s feedback. Please include a title page, headings, and a reference page.
Create a 5-7 minute PowerPoint presentation to present your Social Change project. Within this presentation:
Provide a brief synopsis of social problem and policy you identified.
Discuss what was accomplished over the past term and the change you made through your social change project.
Reflect on your experience. What did you learn? What would you do differently?
Explain how policy relates to clinical practice?
How will you apply skills advocacy skills as a clinical social worker?
Create a Transcript of the presentation