Mental Health Clinic - Clinical Psychology

HPI

Daniel is a 38 year old male with a history of right Symes amputation, with chronic severe pain, substance use disorder, depression, anxiety and PTSD. He is endorsed to our clinic by podiatry and the substance use disorder clinic for evaluation, counseling and cognitive behavioral therapy. 

Adverse Childhood Experiences

• Bullied as a child in school

• Lived in an unsafe neighborhood, building was dilapidated and their apartment had cockroaches

• Father was unemployed and drank alcohol everyday 

• Mother had to work to support the family and therefore was not home much to take care of Daniel and his brother

• Daniel and his brother Sam were very close. However, when Sam told their father he was gay, his father kicked him out of the house

Stressors

Physical: Home is cluttered and crowded. They only have 2 bedrooms, so the 3 kids have to share a bedroom. Daniel and Simone cannot always afford utility bills, so they limit how much they use the heat in the winter. 

Social/Relationship: Simone and Daniel have been arguing. She is upset that he is using their very limited financial resources to obtain pain medication. She also feels he is unsafe supervising their children. Simone accuses him of not being supportive or doing his share of taking care of their home and family. Daniel is frustrated because he feels like she has no idea how much pain he has and feels she is blaming him for their financial struggles. 

Financial: Simone and Daniel are hourly workers and live paycheck to paycheck. They have trouble covering their rent every month and are struggling with medical bills from Simone’s hospitalization and surgery. 

Life Events: Wife, Simone, had a seizure and required ambulance  transportation to the hospital She underwent an emergency C-section and was hospitalized for 4 days.

His youngest son, who is 6 weeks old now, was born prematurely and is having recurrent respiratory problems.

His mother, Evelyn, died of Ovarian cancer last year.

He served in the army and saw active combat in Afghanistan. Sustained a crush injury to his right foot when a building collapsed during bombing 4 years ago. He required an amputation of the right foot. He also saw his friend, Peter, die in the same building collapse. Peter was a fellow soldier on his team. 

Physiologic: Chronic severe pain right lower residual limb. Fatigue due to poor sleep. Feels sluggish and bloated from poor diet and alcohol us 

Mental Status Exam

Appearance: Daniel is somewhat disheveled. He is sitting with shoulders slumped and looking down at the floor.

General behavior: He is cooperative, but has poor eye contact.

Speech: Daniel speaks slowly and softly. At times he mumbles and is hard to understand.

Emotions: He states he feels "depressed and anxious." He feels resigned. He is tired of going to appointments and doesn’t feel like he will ever get better. His pain is awful and he feels panicked that there is nothing anyone can do for him. His employer and his wife do not understand how bad it is and how hard everything is for him. He feels resigned and like giving up. He sometimes thinks that his family would be better off without him. He has thought about “ending it all” but does not have a plan in mind. Doesn’t enjoy things that used to make him happy (anhedonia).

Thinking process: His processes are coherent and organized, but tend to be fatalistic and negative.

Cognition: Daniel is alert but distracted. He scored below average on the Working Memory Questionnaire. 

Insight: He demonstrates poor insight into his condition and behaviors. Daniel feels he is “doing the best that he can” and wishes that everyone would understand that he is in severe, unrelenting pain. He needs the pain medications to “just get by” and cannot help anymore than he is with taking care of the household or his children.

Judgment: Daniel shows poor judgment. His wife reports that he often drives under the influence of drugs and/or alcohol. Sometimes with the kids in the car. He drinks and uses opioids when he is supposed to be watching his children and has actually passed out on the couch as a result, leaving the children unsupervised.

Reliability: His reliability is fair. He has poor insight and did not relate some significant lapses in Judgment. However, what he has shared seems accurate and truthful. 

Patient Goals

1. Improved sleep

2. Pain control

3. Work on his relationship with Simone

4. Stop having nightmares

5. Less nervousness 

6. No panic attacks

7. Improved self esteem and confidence

8. Cut down on alcohol, marajuana and tobacco

9. Get off of pain medications if possible