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ProfUniverseHyena26
Case study John Smith is a 41-year-old married heterosexual…
Case study
John Smith is a 41-year-old married heterosexual Biracial male of no particular religious beliefs. He was born in Chicago, IL to his then 18-year-old mother and 19-year father. His parents were in a relationship but not married at the time. Santos’ parents married when he was a teenager. His parents continue to be married today. John has two biological sisters and two adopted brothers (cousins). John currently resides in Tampa, FL with his wife (35 years old), and 3 (children 10 years old, 11 years old, and 19 years old. John reported he drinks excessively to cope with his wife’s constant nagging.
Family History John’s parents are in fair to good health. They reside together in Chicago, IL. His father has diabetes and heart issues. Santos ascribed his relationship with his parents as “okay.” John has a relationship with his youngest sister. John and his other sister had a disagreement about she was treating her son/his nephew in May, they haven’t spoken since. John described the conflict as “too much.” His sister told him that she was dead to her and verbally attacked his wife. He believes the relationship is repairable but it would require his sister to address his wife. John shared that the status of his relationship with his sister was ” she ‘s annoying.” John shared that he is close with his nephew who lives with his father. His sister had been keeping his other nephew ad niece away from him until recently.
John shared that his relationship with his wife is a little rough right now. He feels like they are roommates. He believes his if has a lot of mental health and trauma issues. He believes they always end up talking about feelings which is too much for him. John shared that he is not a “feeling” person. John believes that his relationships with his children are good. He and his oldest son had conflict in the past but no longer. Santos shared that he used to be a big yeller but not anymore.
John Smith endorsed feelings of discouragement about the future; feeling slightly more irritable than usual; sleep disturbance; worries about physical problems; racing heart; chest pain or pressure; fatigue; shaking; and tension.
John shared that his relationship with his wife is a little rough right now. He feels like they are roommates. He believes his if has a lot of mental health and trauma issues. He believes they always end up talking about feelings which is too much for him. John shared that he is not a “feeling” person. John believes that his relationships with his children are good. He and his oldest son had conflict in the past but no longer. John shared that he used to be a big yeller but not anymore.
Social History John and his wife have been together for 15 years, 12 years married. Santos believes that the past 10 has been rough. They have had parenting issues in the past as well. His wife has experienced sexual trauma that resurfaced 10 years ago. The trauma is gradually taking a toll on the entire marriage. His wife has been in therapy for years and at some points cause her symptoms to worsen. John does not believe their communication is great but it is better. He described feeling frustrated because he is trying o support her but it does not seem that he can do the right thing at the right time. He shared that they struggle with intimacy because it always leads to addressing feelings. John shared that he and his wife may engage in sex twice a week or once a month. It depends on how she feels. He experiences a lost of interest because of the rejection. The couple tends to argue about her role in the home as he does “everything.”
John enjoys watching football during football season. He enjoys taking his children to their softball and baseball games. They also play volleyball and soccer. He enjoys running around with them. Her plays poker once a month. Santos described his social life as good but lacking because his wife dislikes being around people. He has to force her to be around people.
Educational/Occupational History John works from home as a distribution manager. He travels twice a month for his job. He has been a distribution manager for the past 3 years. Prior to his current position he was a yard coordinator with the same company. John shared that he loves his job. He shared that he has worked the graveyard shift for 12 years and hour difficult hours for another 7 years. Now he has an easier schedule. He has been with his current company for the past 7 years. John attend some college. He attended ITT for 6 months when he decided it was not for him.
Present Illness John endorsed feelings of discouraged about the future; feeling slightly more irritable than usual; sleep disturbance; worries about physical problems; racing heart; chest pain or pressure;
Trauma History John shared that he grew up on the West side of the Chicago. He has witnessed people in his neighborhood be shot and killed. His nephew’s father was shot in front of him. John described himself as a very vigilante person, his feelings are numb, he only cares about his immediate circle, he becomes anxious been his hears screaming, he is a light sleepier, he experiences some difficulty sleeping and can beware early. John shared that he is hyperarousal, tense, and worried when out with his children.
Substance Abuse: John shared that he used to drink a lot every weekend in his 20’s. He now drinks occasionally when playing poker. He takes an edible occasionally.
Developmental History Santos denied development
Legal History: John had a felony 20 years ago forgery. He was on probation for 2 years for the offense.
1.What would an example of a Data, Assessment, Treatment (DAT) note with clinical information gathered from the case study above? (Provide APA CITATION PLEASE)
2.What would be verbal and nonverbal information and observations that may arise in a therapy session?
3.Explain how the information gathered in the DAT note contributes to the client’s treatment plan and potential progress?
4.How would the data gathered in the DAT note can affect the utilization review process and contribute to continued authorization of treatment or a possible reduction in level of care?
5.What could be some examples of challenges present in gathering and documenting clinical data in an accurate, concise, and effective treatment note?
