Case Study: Sara Jones is a 26-year-old transgender male referred…

Question Answered step-by-step Case Study: Sara Jones is a 26-year-old transgender male referred… Case Study:Sara Jones is a 26-year-old transgender male referred for an evaluation of his treatment needs at the Outpatient Trauma Therapy (OTT) by his counselor at General Medical Center, Jane Doe.  It is noted that Mr. Jones uses the name John Jones and will be referred to as such throughout the evaluation report, although Sara Jones remains his legal name.  In the referral dated x/xx/21 Ms. Doe reported Mr. Jones experienced sexual abuse and neglect throughout his childhood and is presently experiencing auditory hallucinations, nightmares, racing thoughts, and problems sleeping. Mr. Jones endorsed a history of childhood sexual abuse from 15 to 16 which was perpetrated by his father.  He reported a history of adult sexual assault prior to his transition.  Mr. Jones endorsed a history of neglect during periods of childhood.  Mr. Jones endorsed a history of physical and verbal abuse by his mother, which included being thrown down the steps and being hit with a belt buckle in the face.  He stated that one time he went to school with his eye swollen shut but was afraid to say what happened when asked by the teacher.  He reported his mother frequently said he was a failure or would not amount to anything.  Mr. Jones witnessed domestic violence between family members.  Mr. Jones reported he has been violent in past relationships with partners, but declined to provide further details.  Mr. Jones reported he has been the victim of crime but “I fought back” so “I didn’t get locked up but the other person did.”  Mr. Jones reported that at GMC the staff constantly refer to him as “her or she” which makes him feel very angry.  He stated that he has been treated differently due to gender, race, and sexual orientation.   Mr. Jones denied a history of intimate partner violence. Mr. Jones reported he is Dominican and Black.  He was born in Northeast City and raised by his parents until age 18 when he left home.  Mr. Jones reported his father is sick but they have had no relationship since he was a teenager.  He has an okay relationship with his mother.  Mr. Jones has a good relationship with his siblings.  He denied a history of DHS involvement, foster care, or residential placements.  Mr. Jones reported his first consensual sexual experience was at age 19.  Mr. Jones denied a history of involvement in sex work or prostitution. Mr. Jones graduated from high school in 2013.  He has no history of grade retention or special education. Mr. Jones last worked a year ago in construction which he did for a period of about 4-years.  He has never been fired from a job.  There is no history of United States Military Service. Mr. Jones is currently in residential substance abuse treatment at General Medical Center where he has been for the past 6-weeks after being transitioned there from Science Hospital.  He stated he is going to be transitioning to the “mental health unit” in the next week at GMC for the next 6 to 9 months, which will lead him to assistance in finding housing.  Mr. Jones reported two prior periods of homelessness which were “short” in duration.  Mr. Jones is current single.  Mr. Jones has a prior history of long-term relationships with both men and women.  Mr. Jones reported he has one son, Johnnie (4), who lives with Mr. Jones’s grandmother.  There is no DHS involvement and they have daily contact.  Mr. Jones stated their relationship is “getting there” and then stated he “just found out I have a son, his mom and I lost contact and she just showed up at my grandmom’s house with him.” Mr. Jones reported his physical health is excellent.  Mr. Jones last had a physical examination in March 2021 and he has no chronic health concerns, although he acknowledged he has been diagnosed with HIV.  He stated he was in Jones Hospital 2-years ago due to pneumonia.  Mr. Jones reported surgery related to his transition in 2020.  Mr. Jones has a history of epilepsy since childhood which is well controlled with medication and he last had a seizure about 3-years ago.  Mr. Jones is on methadone (40mg).  Mr. Jones endorsed being on a variety of medications related to his HIV and epilepsy, as well as testosterone.  Mr. Jones previously abused heroin for 11-years, with sobriety for the past few months with methadone.  He denied all other substance use/abuse.  Mr. Jones is currently prescribed methadone (40 mg). Mr. Jones reported he has been arrested 10 times for charges such as forgery, aggravated assault, passing bad checks, and simple assault.  Mr. Jones reported about 2-years ago he was incarcerated for aggravated assault with a deadly weapon.  He endorsed a significant history of misconduct and/or disciplinary violations while incarcerated, but declined to provide details.  Mr. Jones is currently on parole.  He does not currently own any weapons but endorsed making a “shank” while incarcerated. Mr. Jones denied a history of outpatient mental health treatment.  Mr. Jones reported a history of multiple inpatient mental health hospitalizations in the past year.  He reported being hospitalized for one month at Psychiatric Hospital in 2020, one month at University Hospital in 2020, one month at State Hospital in 2020, and several weeks at Science Hospital in January 2021 on an involuntary hospitalization before being transitioned to General Medical Center (GMC).  He reported at age 16 he was diagnosed with Schizophrenia for the first time by his primary care provider, with multiple prior practitioners providing the same diagnosis.  He stated he has also been diagnosed with Bipolar Disorder, Depression, and Paranoia in the past 10-years. Mr. Jones denied a history of suicide attempts but then later stated that in 2020 he attempted to overdose on “a lot of pills” which resulted in him being hospitalized at Psychiatric Hospital and placed on a suicide watch.  Mr. Jones stated he attempted to hang himself 2-years ago.  He denied current suicidal ideation, with last ideation while at Science Hospital.  Mr. Jones endorsed homicidal ideation a few weeks towards “just anybody, nobody particular” which occurred while at GMC.  He stated he reported these thoughts to staff who worked with him to reduce the thoughts.  Mr. Jones endorsed a homicide attempt where he attempted to “shank” someone while he was in jail, which occurred about 2-years ago.Mr. Jones reported his mood has been “okay.”  He endorsed a history of recurrent depressive episodes, most recently last week.  Mr. Jones endorsed loss of interest and pleasure in activities, sadness, low mood, crying spells, low motivation, low energy, fatigue, decreased self-care, and irritability.  Mr. Jones reported that he is able to sleep due to medications but he feels tired all the time.  Mr. Jones reported he continues to have nightmares even with medication.  Appetite is good.  Mr. Jones endorsed avoidance, nightmares, flashbacks, intrusive thoughts, problems with trust, hypervigilance, being easily triggered to distress, avoidance, and hyperarousal.  Mr. Jones endorsed frequent irritability.  He reported anxiety but was not able to provide details of the situations of anxiety, duration of anxious distress, or triggers for anxious thoughts.  He reported fears of heights and death.  Mr. Jones denied all evidence of mania outside the context of substance abuse.  He endorsed hyperactivity, impulsivity, and distractibility.  Mr. Jones endorsed auditory hallucinations including voices urging him to kill other people, telling him to stab people, and slitting the throats of others, which last occurred one week ago.  Mr. Jones endorsed visual hallucinations of “dark shadows.”  Mr. Jones endorsed problems with anger that include being explosive and a history of related aggression.  He acknowledged a history of physical aggression, which has included fights while hospitalized and while incarcerated.  He endorsed prior conviction for aggravated assault with a deadly weapon.  He stated he has gotten into physical altercations while at GMC.Mental Status Examination:Mr. Jones presented with “okay” mood and blunted affect.  Rapport was easily established and comfortably maintained, although Mr. Jones was noted to be very tired and lethargic during the interview.  Speech was normal overall, although at times it was slow and slurred which appeared to be related to drowsiness.  Thought processes were linear, coherent, and goal directed.  Mr. Jones endorsed significant paranoia despite medication. He reported auditory hallucinations one week ago which include voices urging him to kill other people, stab people, or slit their throats.  Mr. Jones also endorsed visual hallucinations of shadows.  Mr. Jones endorsed a history of recurrent depressive episodes with no evidence of mania outside the context of drug use.  Mr. Jones endorsed anxiety but was not able to provide details of anxious thought content.  Mr. Jones endorsed flashbacks, intrusions, nightmares, guilt, hypervigilance, hyperarousal, and avoidance.  He reported homicidal ideation stemming from his auditory hallucinations.  Mr. Jones was stuporous, including falling asleep numerous times during the interview, and was not able to maintain a state of alertness.  He was oriented to name, location, and date.  Remote and recent memory were fair as assessed and immediate memory was poor.  Concentration and attention were poor, as Mr. Jones could not maintain focus or attention related to his state of drowsiness.  Abstraction and general fund of knowledge could not be assessed.  Insight and judgement are poor by history but fair as assessed.  Mr. Jones was friendly and cooperative with the evaluation overall.  Mr. Jones reported a history of at least two suicide attempts, including an attempted hanging 2-years ago and an overdose on “pills” about 3-years ago.  He reported his last suicidal ideation occurred a few months ago while hospitalized at Science Hospital.  Mr. Jones denied a history of non-suicidal self-injury. Mr. Jones reported an attempt to stab a peer while incarcerated 2-years ago, along with ongoing issues related to his auditory hallucinations which include command auditory hallucinations to harm others.  He stated his last homicidal ideation was a few weeks ago at GMC with thoughts towards “anyone” which he addressed with staff at GMC.  1.  A diagnostic formulation for the client, including use of all appropriate diagnoses with specifiers and codes, with clear explanation of the diagnostic criteria for the diagnosed disorder(s) and how the client’s symptoms align with those diagnoses.  Include V-Codes if warranted.2.  A minimum of 2 differential diagnoses, with clear explanation of the diagnostic criteria for the diagnoses that were ruled out and why the client’s symptoms were determined not to align with these disorders.3.  Treatment recommendations for the client supported by a minimum of three scholarly articles published within the past 5-years.4.  Consideration of any diversity variables that may be present and how those variables impact consideration of symptoms, treatment, or understanding of the client.5.  Identification of any ethical or legal issues that may need to be addressed.6.  Referrals to any other professionals that would be appropriate for evaluation, collaboration, or additional interventions. 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