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Tag Archives: The Assessment Process sections of the treatment plan that you will complete for this assignment consist of the following.

August 19, 2024
August 19, 2024

 Medical Treatment Case Study

For this assignment, complete the Assessment Process sections of the treatment plan for your course project. This treatment plan is based on the case study you selected for your course project. You can review the case studies in the Case Study Treatment Plan media piece available in the resources.

The Assessment Process sections of the treatment plan that you will complete for this assignment consist of the following:

  • Identifying information.
  • Presenting problem.
  • Previous treatments.
  • Strengths, weaknesses, and social support systems.
  • Assessment
  • Diagnosis
  • References

The sections of the treatment plan you submit for this assignment should be 4–5 pages in length, with a minimum of two references from current articles in the professional literature in counseling. Be sure to cite your references in current APA format.

Medical Treatment Case Study

 Medical Treatment Case Study

To assist you in completing this assignment, please use the Case Study Treatment Plan Template (available in the resources) to organize your work. Each section of the template includes a description of the type of information you must include. You should type your paper directly into this template, save it as a Word document with your name, and then submit it to the assignment area.

For additional information, see the course project description.

Submit your paper to Turnitin before you post it to the assignment area so you can catch any areas that are showing up as possible plagiarism.

Note: Your instructor may also use the Writing Feedback Tool to provide feedback on your writing. In the tool, click on the linked resources for helpful writing information.

Case  

Oscar is a 19-year-old Hispanic male who is the oldest of 5 children. His family has been farming the same land for 4 generations. Currently they grow vegetables for the regional grocery chain’s produce departments. They live in a rural area of the county. Three generations live in two separate houses on their land. They are fiercely independent and have little to do with people in town, although the family itself is extremely close knit.

 Medical Treatment Case Study

Oscar is currently a freshman at the same college his father attended, majoring in agriculture. When he came home for spring break, his parents noticed significant changes in his appearance. He had lost weight, looked haggard, wasn’t sleeping and seemed irritable and argumentative. He told his parents that he did not want to return to college after the break. He went on to say that his roommate had placed cameras in the room so he could record everything Oscar did while the roommate was absent. His grades were poor, and he expressed that he believed his instructors were prejudiced against him. This poor performance was in stark contrast to his performance in high school, where he was in the top 10% of his class. Within days of coming home, he had stopped showering and began wearing multiple layers of clothes (3 pairs of jeans and 4 t-shirts). He became essentially non-communicative, responding to questions with one-word answers and not initiating conversation. Oscar seemed unhappy or irritable whenever he encountered a member of his family and began spending all his time in his room. He even refused to talk with his youngest brother, with whom he had always been close. He did not take meals with his family, a long-standing tradition in his family, and left his room only in the middle of the night. He could then be heard opening drawers in the kitchen, going into his siblings’ rooms and leaving the house for long periods of time.

The family (parents and grandparents) became very disturbed and consulted their priest. The priest recommended that the parents take Oscar to see a fellow parishioner who is also a counselor. This counselor was also disturbed with Oscar’s presentation and recommended hospitalization. The family was very reluctant, but eventually agreed. By the time they got to the hospital, Oscar was essentially non-communicative, only nodding or shaking his head in response to direct questions.

 Medical Treatment Case Study

The parents provided history that indicated Oscar had been a good student in high school and had participated in the school’s FFA club. He has always wanted to carry on the family tradition of farming. He did not have many friends, but the family attributed that to their living in the country.

The psychiatrist diagnosed Oscar with major depressive disorder, single episode, severe with psychotic features and prescribed anti-depressants. He was released three weeks later, with some improvement. One week later he was readmitted, with the same presentation he had at the previous admission. This time, though, his father reported that he had found a cache of knives in the barn, some from the house, some from the grandparent’s house and some from the barn itself. When he asked Oscar about them, Oscar responded that he needed them to protect himself from attacks. When his father asked from whom, Oscar responded that he had seen one of his college professors in the field of broccoli. That same day, Oscar’s mother found notes stuffed between Oscar’s mattress and box springs in Oscar’s handwriting. The content of them was Oscar arguing with someone about killing his younger siblings. One side did not want to do it and begged to not have to; the other side ordered the killings, saying that was the only way to keep them safe. In light of these two events, both parents were afraid for Oscar to remain at the house. Oscar swore that he would never hurt any of his family and said that was why he had been keeping away from them. His parents could not be sure that no harm would come and were unable to watch Oscar day and night. Therefore, they readmitted him to the hospital.

 Medical Treatment Case Study

During this admission, Oscar was more forthcoming with his treatment team. Once they had this additional information, the team realized that Oscar’s initial diagnosis had been wrong. They began a re-assessment. Oscar acknowledged that the problems began about the time of the new semester. He was unable to complete his schoolwork, as he was “consumed” with the need to follow instructions that were being given to him. These instructions actually began with a buzzing in his head, which quickly evolved into specific directions. When pressed, he acknowledged that he did not know who was giving him the directions, though he sometimes thought it might be Jesus. These instructions were for him to keep a log of every time he heard a door close on his hallway in the dorm. Oscar came to believe that doing this was the only way to keep his family safe from dark angels. Oscar tried to keep these voices quiet by smoking marijuana on a daily basis. While this helped in the short term, it also made it more difficult for him to complete any of his schoolwork. By the time for spring break, the messages had begun to change. He was no longer able to keep his family safe by keeping a list; the voices told him he would have to kill them. Oscar knew that he did not want to kill his family. He could also not avoid going home for spring break. Therefore, he devised the plan to isolate himself.

 Medical Treatment Case Study

Once the family recovered from their initial shock and as Oscar began to show some improvement with his new, anti-psychotic, medication, his parents and grandparents wanted to take him home to the farm. They believed that life on the farm, being outside and with hard, physical labor would cure Oscar. Finally, Oscar agreed to tell them what has been happening with him. At that point, the family agreed to residential treatment for Oscar. When asked if anyone else in the family has ever had symptoms like this, the grandfather acknowledged that he had a brother (Oscar’s uncle) who had religious visions. This brother left the family and became a monk. Later the family heard that he had died under mysterious circumstances. One of the other monks at the monastery told Oscar’s grandfather that his brother had died from engaging in a prolonged fast. The family is very lucky on two counts: 1) they have their medical insurance through the farmer’s co-op, and it includes coverage for residential treatment for up to a year, and 2) this hospital has a residential treatment unit for late adolescents and young adults. You are working as a counselor at the Residential Treatment facility where Oscar has been placed. He will be here for a minimum of 6 months and as long as one year. Professional staff at this facility includes 3 counselors, an addictions counselor, a social worker (currently on maternity leave), a psychologist, and 2 nurses on every shift. Oscar’s psychiatrist is also on staff and will continue to follow his care.

The social worker usually coordinates clients’ treatment plans; however, she is currently away on maternity leave so you will be the lead therapist who is coordinating Oscar’s treatment during the next 45 days. Once she returns, you will collaborate with her for developing Oscar’s post-residential treatment and resources for him and his family.

July 3, 2024
July 3, 2024

Oscar Treatment Case Study

Identifying Information

Oscar is a 19-year-old Hispanic male, currently a freshman at a college majoring in agriculture. He is the eldest of five children in a family that has been farming the same land for four generations. His family grows vegetables for a regional grocery chain and lives in a rural area of the county. The family is very close-knit and highly independent, with three generations living in two separate houses on their land. Despite their strong family bonds, they have minimal interaction with people outside their family, preferring to maintain their independence from the local town’s community.

Oscar has always been seen as a responsible and hardworking individual, traits instilled in him by his family’s farming background. His commitment to carrying on the family tradition of farming and his enrollment in college to study agriculture demonstrate his dedication to this goal. However, recent behavioral changes have raised significant concerns among his family members, leading to his current treatment at a residential facility.

Oscar Treatment Case Study

Presenting Problem

Oscar’s parents observed drastic changes in his appearance and behavior when he returned home for spring break. He had lost a noticeable amount of weight, looked physically exhausted, and exhibited signs of sleep deprivation. His mood was markedly different; he was irritable, argumentative, and no longer engaged in regular family activities. Oscar expressed a strong reluctance to return to college, citing paranoia that his roommate had placed cameras in their room to record his actions and that his professors were prejudiced against him. These concerns were accompanied by a significant decline in his academic performance, which was a stark contrast to his high school achievements where he was among the top 10% of his class.

In addition to these changes, Oscar began exhibiting unusual behaviors. He stopped showering, started wearing multiple layers of clothing regardless of the weather, and became almost completely non-communicative. He isolated himself in his room, avoided family meals, and only left his room in the middle of the night to wander around the house and property. His family, deeply disturbed by his behavior, sought advice from their priest, who recommended professional counseling. This led to Oscar’s hospitalization and the beginning of his formal mental health assessment and treatment.

Oscar Treatment Case Study

Previous Treatments

Oscar’s initial treatment involved a diagnosis of major depressive disorder, single episode, severe with psychotic features. He was prescribed antidepressants and hospitalized for three weeks. During this period, he showed some signs of improvement but relapsed shortly after being discharged. Upon his second hospitalization, it became evident that the initial diagnosis did not fully capture the severity and nature of his symptoms.

During his second stay, his condition was reassessed. He exhibited continued non-communicative behavior, persistent delusions, and paranoia. The discovery of a cache of knives and delusional notes about harming his siblings further indicated the presence of severe psychotic symptoms. This prompted a revised treatment plan that included antipsychotic medication. The re-assessment revealed that Oscar’s symptoms were more consistent with a diagnosis of schizophrenia rather than major depressive disorder with psychotic features.

Oscar Treatment Case Study

Strengths, Weaknesses, and Social Support Systems

Strengths

Family Support: Oscar’s family is deeply committed to his well-being, providing emotional support and actively participating in his treatment decisions. Their close-knit nature means that Oscar has a strong, reliable support system.

Motivation for Improvement: Despite his severe symptoms, Oscar has shown moments of clarity and willingness to communicate with his treatment team, indicating a desire to improve his condition.

Insurance Coverage: The family’s medical insurance through the farmer’s co-op covers residential treatment for up to a year, ensuring that Oscar has access to the necessary long-term care without financial strain.

Weaknesses

Social Isolation: Oscar has minimal social interactions outside his immediate family, which can hinder his social development and limit his support network. His lack of friends and social activities outside the family contribute to his isolation.

Severity of Psychotic Symptoms: Oscar’s hallucinations and delusional thoughts present significant challenges to his treatment and daily functioning. These symptoms have led to behaviors that are disruptive and potentially harmful.

Communication Barriers: Oscar’s tendency to withdraw and provide minimal responses makes it difficult for healthcare providers to fully understand his experiences and needs, potentially slowing his treatment progress.

Social Support Systems

Family: Oscar’s parents and grandparents are actively involved in his care, providing a consistent and supportive presence. Their commitment to his recovery is evident in their willingness to seek professional help and participate in his treatment.

Religious Community:  The family’s priest has been a source of guidance and support, offering spiritual and emotional comfort during this challenging time.

Residential Treatment Facility: Oscar has access to a multidisciplinary team of professionals, including counselors, a psychologist, and a psychiatrist. This team approach ensures that he receives comprehensive care addressing his diverse needs.

Oscar Treatment Case Study

Assessment

Oscar’s assessment began with a comprehensive evaluation by his treatment team during his initial hospitalization. This included detailed interviews with Oscar and his family, a review of his medical and psychiatric history, and observations of his behavior. The initial diagnosis of major depressive disorder with psychotic features was based on his reported symptoms of paranoia, hallucinations, and severe depression.

However, his re-admission and subsequent behaviors led to a re-assessment. The discovery of knives, delusional notes, and Oscar’s detailed accounts of auditory hallucinations provided new insights into the nature and severity of his condition. These additional findings indicated that Oscar was experiencing persistent and severe psychotic symptoms, warranting a diagnosis of schizophrenia. The re-assessment involved further interviews, psychological testing, and consultations with the treatment team to develop a more accurate and effective treatment plan.

Diagnosis

Oscar’s revised diagnosis is Schizophrenia, characterized by the presence of persistent auditory hallucinations, delusional thoughts, social withdrawal, and significant impairment in daily functioning. This diagnosis is supported by his symptoms, including the belief that he needs to protect his family from perceived threats, hearing voices giving him instructions, and his severe behavioral changes since the onset of his condition.

The diagnosis of schizophrenia also aligns with the family history of similar symptoms, as indicated by the grandfather’s brother who experienced religious visions and later died under mysterious circumstances. This genetic link further supports the diagnosis and underscores the importance of a comprehensive treatment plan that addresses both the psychotic symptoms and the underlying genetic predisposition. APA.

References

American Psychiatric Association. (2013). *Diagnostic and statistical manual of mental disorders* (5th ed.). Arlington, VA: American Psychiatric Publishing.

Kaplan, G., & Sadock, B. (2015). *Synopsis of psychiatry: Behavioral sciences/clinical psychiatry*. Wolters Kluwer.