Practice Assessment Clinical Case Term Paper

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Total Length: 3226 words ( 11 double-spaced pages)

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Gender: Female

Birthdate: 01/16/1985

Age: 30 years, 11 months

Dates of Evaluation: 10/25/15 -10/30/2015

Reason for Referral

This is a 30-year-old right-handed woman referred by Dr. Smith for a psychological evaluation to determine any lingering psychological and cognitive effects as a result of a mild head injury that she suffered on October 15, 2015 as a result of an automobile accident. The client has complained of severe memory problems, being disoriented at times, feeling depressed and anxious, and having nightmares the accident. Her physical complaints consist of headaches, back aches, poor sleep, nausea, and vomiting.

Identifying Information

The client is a 30-year-old, divorced, Hispanic woman who lives with her children in a home that she rents in XXX (client please insert city). She has been married three times and has three children from two of the marriages.

Developmental History

The client grew up in XXXX (insert). She reported that her mother had no issues with her pregnancy and that she was born at full term. She is the third child in a sibship of seven. All developmental milestones were met at appropriate times and did experience any developmental delays or issues with motor tasks, language acquisition, or toilet training. Her primary language was Spanish and she told me that she learned English when she went to formal school.

Medical History and Psychiatric History

According to her self-report and to medical records, the client was a restrained driver who was driving after stopping at a four-way stop when her car was struck on the driver's side front quarter panel by another car. Her airbag deployed. The other driver fled the scene and has not been found. She reported that she experienced a brief loss of consciousness of unknown duration and she was taken to Fredrciks Hospital Emergency Department (referred to as ED in this report) where she obtained a Glascow Coma Scale score (GCS) of 14. She was able to vividly recall the accident, her ride in the ambulance, and speaking with medical personal. Her orientation was reportedly intact for person and place, but temporal her orientation was slightly off according to time of day according to the medical record. Reports also indicate that she was anxious and had a very mild left scalp abrasion; however, CT scan of the brain was negative for acute changes and a CT scan of the spine was also negative. She was admitted to the hospital where she claims she remained for three days; however, the records provided to me indicated that she was discharged the next day on 10-16-2015. She was discharged home.

The client has complaints of pain, confusion, depersonalization (feeling that her legs were not part of her body), and other vague ailments. There are reports of six ED visits before her MVA and three shortly after the accident. Her complaints before the MVA that led to her ED visits consisted of anxiety related to financial concerns, difficulties with ulcerative colitis, stroke-like symptoms which were thought to be related to her anxiety, and paralysis related to deep vein thrombosis (DVT) in her right arm. The patient discussed these admissions and was offended that there was an insinuation in the reports that she was medication seeking. Nonetheless, three subsequent CT scans of the brain obtained in response to the patient's complaints of cognitive problems and headaches failed to reveal any evolving acute cerebral changes. I also note mention of two EEG's (10/18/2015; 10/20/2015) ordered by her physician. Results of these tests have also been reported as unremarkable. Her physical complaints at these visits consisted of her having headaches, back aches, poor sleep, nausea, and problems with memory.

Psychiatric History

The client's psychiatric history is remarkable for depressive symptoms during an admission in January of 2014 for treatment of her DVT. She also reported being physically and sexually abused by her three ex-husbands, but denied significant emotional distress as a result of that experience. I am not able to find mention of this prior abuse in any other of the medical reports provided to me by her case manager. The patient was diagnosed with an adjustment disorder and a history of post-traumatic stress syndrome (which is equivocal given the information in the reports).

According to the information presented in medical records the patient received significant assistance and supervision from her family following her accident, but over time this has apparently decreased. She received PT, OT, Speech Therapy, as well as psychiatric support following her discharge from the hospital.

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According to the records I have been provided with she made good progress in her therapies; however, based on the results of her most recent evaluations her insurance has stopped funding further rehabilitation. She was not driving, going to school, or working at the time of this evaluation.

The client's current medications are reviewed based on a list of medications provided by her. The client's current active medical regimen according to this list consists of Tylenol, Lunesta, Ultram, Cymbalta, Xanax, and Ambien. She does not smoke and denied a history of drug or alcohol abuse.

Academic and Employment History

The client he reported that she graduated from high school on her history form, but records indicated she obtained a GED. When confronted with this discrepancy she admitted that she dropped out of high school as a junior in order to work full-time and obtained a GED. She reported that her grades in high school were "above average" even though she was held back in the tenth grade. She was never identified as having a learning disability or was involved in special education classes.

The client reported that she was preparing to go to school to be a nursing assistant at the time of her accident. She has completed one year of college and just began classes again shortly before her accident. She did not return to school following her accident and reported that she does not retain material that she reads now, whereas this was not a problem for her prior to her accident. She discussed trying to read and recall information from an anatomy book she was reading and how this was very difficult for her. As a result the patient is concerned about returning to school in the future. Regarding her grades, the patient reported her college GPA as a 3.40 on the history intake form she completed during her lunch break during the first evaluation which is somewhat lower than her previous report to me during the initial interview of a grade point average of 2.20.

With respect to her employment, the client was an interviewer for a research project at a local university. She apparently took a leave from her position following her accident, as would be expected. According to her self-report she attempted to return to work "too soon" after her accident leading to some difficulties interviewing clients and she subsequently was let go. She has also worked as a waitress at several restaurants. She was not working at the time of this evaluation.

Tests Administered

Mini Mental Status Examination

Wechsler Adult Intelligence Scale-III (WAIS-III)

Minnesota Multiphasic Personality Inventory-II (MMPI-II)

Millon Clinical Multiaxial Inventory-III (MCMI-III)

Mental Status and Behavioral Observations

The client was accompanied to the evaluation by her case manager, Martha Stewart and her personal friend Natasha Bardernoff. The initial interview was completed with both present. The client did not fully fill out the consent form or release forms, but instead had her case manager or friend completed much of the information on the forms and then the client signed them.

During the evaluation the patient was cooperative and friendly. Affect was depressed at times and eye contact was intermittent. Expressive language was fluent but with occasional word finding difficulties. She displayed frustration with several tests, especially tests that appeared to challenge her. Several times during the evaluation she openly expressed frustration when she perceived she was not doing well or during tests when she received feedback about her performance. The patient also became tearful when we discussed her mood and reaction to her current state of affairs (not working, etc.). Otherwise, the evaluation was completed without incident. Performance on several measures often used to assess motivation and effort was variable and observations during several measures indicate that the patient may not have been putting forth a full effort at all times. However, I do not believe that there is an overt intentional effort on this patient's part to present as frankly impaired and I will discuss this further in this report. The present evaluation addressed orientation, general intellectual ability, and personality and emotional functioning

Mental Status Evaluation

MMSE: 25/30 (Problems with Immediate recall and attention)

1. Appearance

A. Neatness: dirty, disheveled, meticulous appropriate.

B. Clothing: unusual, bizarre, inappropriate, age appropriate.

2. Behavior

A. Posture: slumped, rigid, inappropriate, appropriate.

B. Body movements: accelerated, slowed, restless, agitated, peculiar, appropriate.

C. Attitude: submissive, domineering, hostile, appropriate, suspicious, provocative, guarded, cooperative.

D. Gait: unusual, shuffling, staggering, unremarkable.

E. Eye.....

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