Intake Assessment and Comprehensive Treatment Plan Assignment

Mr. Bill Billings is a PTSD client who is struggling with his transition from military service to civilian life. Psychotherapy, medicine, and support techniques are all part of his treatment strategy. Triggers, coping mechanisms, social networks, experts, and environmental safety precautions are all included in the safety plan (WHO, 2021). Developing good coping mechanisms and expanding social support are the main objectives of SMART goals. Exercise, mindfulness, and self-care are examples of preventive strategies. The goal of the plan is to enhance Mr. Billings’ general health. Intake Assessment and Comprehensive Treatment Plan Assignment

Reflection

Reaction

My comprehension of the difficulties in diagnosing and treating PTSD patients has increased as a result of this activity. Navigating the client’s experiences and difficulties while acknowledging the practical consequences of such conditions has a profound emotional impact.

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Source

My emotional reaction was influenced by the client’s story’s depth and realism. The academic information became more tangible through the detailed accounts of pain and the hardships faced in civilian life, which increased empathy and a sense of duty.

Implications

This incident emphasizes how important it is for mental health professionals to always be learning and to be sensitive. Effective intervention requires an understanding of how theoretical information is applied in the real world (Hagger & Weed, 2019). It highlights how crucial it is for students to grow resilient and uphold professional limits. Intake Assessment and Comprehensive Treatment Plan Assignment

Plan

I intend to look for more experience learning opportunities, including case studies and simulated scenarios, to improve my expertise. This will help me hone my abilities to evaluate patients and create all-encompassing treatment plans while retaining the emotional fortitude required to provide client-centered care.

Conclusion

The extensive admission and treatment plan for Mr. Bill Billings illustrates the difficulties experienced by those with PTSD who are leaving the military and moving into the civilian world. It demonstrates a comprehensive approach to mental health care by integrating medicine, psychotherapy, and safety strategies. This event increased knowledge about mental health issues and emphasized the value of professional limits and ongoing education. Intake Assessment and Comprehensive Treatment Plan Assignment

References

Hagger, M. S., & Weed, M. (2019). DEBATE: Do interventions based on behavioral theory work in the real world?. International Journal of Behavioral Nutrition and Physical Activity, 16(1), 1-10. https://ijbnpa.biomedcentral.com/articles/10.1186/s12966-019-0795-4

World Health Organization. (2021). Strategic toolkit for assessing risks: a comprehensive toolkit for all-hazards health emergency risk assessment. 

REASON FOR VISIT

SOURCE OF REFERRAL: Self-referred at the request of the client’s spouse

CHIEF COMPLAINT:” I feel like I don’t belong in the civilian sector. Ever since I retired my nightmares have worsened, I’m angry most days and I have horrible thoughts”. Intake Assessment and Comprehensive Treatment Plan Assignment

HISTORY OR PRESENT ILLNESS:

Mr. Bill Billings is a 38-year-old Caucasian male, married, recently retired from the U.S. Army where he served as a helicopter flight engineer. He is currently a part-time college student and working full-time employed at a Lowes hardware store. He is domiciled with his wife and two young children. He reports feeling depressed at times, easily angered, sleep disturbances, and primarily inability to fall asleep. He reports upsetting nightmares as well as intrusive disturbances of thought while awake that have become more frequent. Many of these thoughts were described as flashbacks to deployments, unwanted violent imagery, and are upsetting to him. He admits to having killed enemy combatants on his second deployment as well as being a Purple Heart recipient for injuries he sustained when his helicopter was shot down in Afghanistan. This accident resulted in multiple injuries to himself and the deaths of both of his pilots and several passengers. Mr. Billings stated that his anxiety has “gotten out of control” as he does not like leaving the house at all lately. Intake Assessment and Comprehensive Treatment Plan Assignment

He describes his social life as dismal, and he has stopped communicating with his friends from the military. He associates his flashbacks being triggered when seeing his former unit members and that seeing them also makes him depressed that he isn’t still serving.  He has stopped attending his son’s baseball games because the “large crowds” make him feel uneasy.  The client mentions that he first recalls noticing these symptoms when he was 22 years old after returning from his first combat deployment in Iraq. He describes being able to “compartmentalize” his emotions because people’s lives depended on his ability to focus on the job. He has no other psychiatric history. Mr. Billings was self-referred under pressure from his wife for worsening intrusive thoughts, flashbacks that “almost feel as if they’re real”, depression, and he admits to feelings of isolation, anhedonia, and anxiety related to recurrent intrusive thoughts. He explains that his overall deteriorating mental health state has caused him to have impaired concentration as a student, causing him to drop out of his classes. He reports his “issues” are affecting his performance at work, stating he is reclusive and avoids talking to customers. Intake Assessment and Comprehensive Treatment Plan Assignment

The symptoms began three months ago after he officially retired from the Army and began to transition to life as a civilian. Today, he rates his feelings of anxiety as a 9 out of 10. Mr. Billings states he feels irritable every day and states he has had many angry outbursts directed towards his wife and children. He states that his current symptoms are worsening in severity, but he doesn’t want to be bothered by anyone about it.  He has recently started to have ruminations about his crash. He relates feelings of guilt for not “dying with his teammates in that crash.” He states that nothing seems to help improve his mood other than smoking weed. He reports 4-6 hours of sleep, which is a change from his baseline of 7 to 8 hours of sleep per night. He reports a decreased appetite without noticeable weight loss. Mr. Billings states that he has no intent or plan for suicide but does associate thoughts about death. Client denies ever attempting suicide in his lifetime, denies ever being hospitalized for mental health issues, denies any active SI/HI or drug use other than cannabis, and admits to alcohol use, typically one glass of bourbon after dinner. Intake Assessment and Comprehensive Treatment Plan Assignment

PSYCHIATRIC AND MEDICAL REVIEW OF SYSTEMS

Mania: Denies symptoms of mania.

Depression: Patient describes dysphoria that does not meet criteria for MDD per DSM-5TR.

Anxiety/panic: Patient reports feeling anxious every day. He expressed his concern that he is becoming increasingly irritable related to his flashbacks from combat experiences, nightmares, and subsequent loss of sleep. He’s self-reported avoiding large crowds and his discomfort with being in situations that he can’t control.

Obsessions/compulsions: Patient has persistent intrusive thoughts related to combat experiences.

Trauma: Multiple combat deployments; helicopter crash which resulted in injuries to the client and deaths of his teammates.

Psychosis: Denies hallucinations or delusions.

Memory/Concentration: Impaired concentration.

Sleep: Estimated between 4-6 hours of sleep each night. Difficulty falling asleep, and interrupted sleep related to nightmares. Pt will occasionally use marijuana to help him fall asleep.

Appetite: Patient reports a poor appetite that he has “fixed” by recreationally smoking marijuana. Intake Assessment and Comprehensive Treatment Plan Assignment

Neuro: Headaches 2-3x per week. Denies dizziness, blurred vision,

Cardio: Denies chest pain. Heart “races” during high-stress situations.

Respiratory: Denies increased work of breathing, or cough.

GI: Occasional nausea experienced along with headaches. Occasional occurrences of diarrhea when distressed. Patient denies vomiting, abdominal pain, or constipation.

GU: Denies incontinence, pain, or urgency.

Pain: Patient reports muscle tension in his shoulders and complaints of lower back pain with prolonged sitting. He uses a heating pad at night as needed

CURRENT MEDICATIONS: Excedrin Extra Strength 1-3 times per week for headaches.

PSYCHIATRIC HISTORY:

Medications: None

Hospitalizations: None

Counseling/Therapy: Critical incident stress debriefing in 2014. Pt reports attending mandatory outpatient session after duty-related fatal accident. No other follow up therapy.

Suicide Attempts: None

Substance Use: Cannabis 2-3 times a week Intake Assessment and Comprehensive Treatment Plan Assignment

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MEDICAL HISTORY:

Illness/Injuries: Facial fractures secondary to blunt force trauma, and 2^nd and 3^rd degree burns on LUE sustained during military duty related aviation accident.

Surgeries: Vasectomy, skin grafts on LUE

Allergies: NKDA

Pregnancy/Contraception: N/A

HABITS:

Alcohol: 1 glass of bourbon 4-5 nights a week

Drugs: Cannabis 2-3 times a week

Caffeine: Coffee 1 cup daily. Occasional energy drink while at work.

Tobacco: None

Supplements: None

FAMILY PSYCHIATRIC HISTORY: Mother diagnosed with major depressive disorder after loss of a child. No paternal psychiatric history reported.

PSYCHOSOCIAL HISTORY:

Developmental and Educational History: No developmental delays or concerns reported. Highschool graduate. Military training and Associate Degree in Aviation Operations earned while in the Army.

Current Family: Wife 38-year old, Son 9-year old, Son 11-year old.

Social Supports/Faith: Client reports he has stopped hanging out with his friends from the military but still talks with them via text. Occasionally has barbecues with neighbor. Patient was raised in the Catholic faith but has not attended church in over a decade.

Adverse life events: Lost two siblings in a motor-vehicle accident while he was in high-school. No other notable traumatic experiences prior to his military duty. Intake Assessment and Comprehensive Treatment Plan Assignment

OBJECTIVE

MENTAL STATUS EXAMINATION:

Appearance: Appeared stated age, muscular build, clean clothes, well-groomed beard and hair. Wearing wedding band. Visible scars on left arm. Client maintained eye-contact throughout interview.

Orientation: Oriented to person, place, time and situation.

Concentration: Impaired concentration. Patient requested several questions to be repeated.

Manner: Appropriate eye contact, normal gait. Appropriate posture while seated. Restless fidgeting throughout the interview. No twitches or tics noted. Guarded at times with questioning related to anger outbursts.

Speech: Clear fluency, rapid at times. Initially, minimal in quantity, which transitioned to talkative. Increased voice inflection, however, at appropriate conversational volume.

Mood: Sad, dysphoric with complaints of anxiety.

Affect: Anxious/dysphoric state. Restricted range. Appropriate to contextual elements. Congruent with patient’s state mood.

Thought Process: Organized linear, logical and coherent. Occasional racing thoughts encountered while discussing distressing topics.

Thought Content: No delusions. No compulsions, client describes recurrent and distressing flashbacks from his military service. Client demonstrates perseverations related to thoughts of death. No suicide plans; client denies passive or active ideation. No homicidal ideation.

Perceptions: Denies auditory and visual hallucinations. Denies illusions.

Memory and Cognition: Not formally tested but grossly intact throughout interview.

Judgment: Fair.

Insight: Fair. Partial awareness of needing help but reluctantly agreeable.

Purpose:

To present a full intake with comprehensive treatment plan.

Instructions:
– Together, use feedback from Parts 1, 2, and 3 to correct any mistakes and issues.
(I WILL ADD THIS AS AN UPLOADED DOCUMENT)

**** Individually (without your partner) write a 1-2 paragraph reflection at the end of the document that addresses the following:****Intake Assessment and Comprehensive Treatment Plan Assignment

1. Reaction (your reaction to the intake itself, the activity, how you felt that it went)

2. Source (the source of your reaction; did something in particular affect that reaction?)

3. Implications (what does this mean for you as a student in the future?)

4. Plan (how will you change because of the activity?)Intake Assessment and Comprehensive Treatment Plan Assignment