Example Case

Almgren

Assignment Guidelines: Use the problem based assessment format as described in lecture to assess this case. Identify any theoretical perspectives that are guiding your assumptions, learning goals, and some of your interventions.

Scenario:

Assume you are the newly hired social worker in a primary care practice clinic in a mid-sized industrial city. You are taking the place of a social worker who abruptly left the position one week ago after a salary related argument with the clinic manager. You are now trying to pick up the pieces. Although all of the prior social worker’s appointments were canceled, you note that Margo Smith-Winston, a long time patient with the clinic insists that she must keep her appointment with the social worker scheduled for 1:00 PM in the afternoon (a few hours from now). In order to prepare for the appointment, you review her clinic record.

Record Review Profile:

There are two sources of information in the clinic record. One is a series of clinic notes written by her primary care physician, Dr. Richard Kiley. The other source of information is a psychosocial summary dictated by the prior social worker a few hours before her termination from the clinic. The medical information is fairly sparse, essentially describing Margo Smith-Winston as a 35 year old single mother with a history of M. S., which has been mostly asymptomatic with only occasional bouts of weakness and fatique. Otherwise her medical history is unremarkable, over the past 5 years that she has been a patient of the clinic she only made appointments for bouts of influenza, and episode of bronchitis and bi-annual pap smears and mammography. Her only recorded injury was two years ago and is described as a jogging accident which resulted in bruises to her face and a sprained ankle. She as two children, a son aged 12 and a daughter aged 17, both were normal deliveries without complications. The social workers intake summary however, is quite detailed and is recorded as follows:

Patient: Margo Smith-Wilson

Age: 35

Reason for Referral: "Insomnia, Relationship Problems"

Demographic Data:

Single mother, two children: Seth age 12 and Chrystal age 17

Employment: Star Systems Micro-computers, Network Consultant

Insurance: Metro-Health

Presenting Problem

Margo was referred to me this morning by Dr. Kiley for psycho-social assessment of her inability to sleep longer than a few hours over the past 3 weeks. When asked by Dr. Kiley if there was anything going on her in her life that might contribute to insomnia, Margo said she had some very serious relationship problems going on. Dr. Kiley prescribed Dalmane and advised Margo to see me. According to my brief conversation with Dr. Kiley Margo readily agreed to this suggestion.

Intake Interview

Margo was very tense and nervous at the beginning of the interview. She appeared very drawn and tired and was easily startled by small background distractions. Her answers to my questions were brief initially, and she seemed to be struggling with whether to proceed with the interview, once saying "Look, maybe it’s just a case of no sleep for too long and the medication will take care of it". When I commented that Dr. Kiley had mentioned "relationship problems", she began to cry and finally blurted out "I’m going to lose him, I’m going to lose it all". She then begin to tell me about the onset of her personal crisis. Her presentation of the information was for the most part coherent, with periodic episodes of tearful silence.

For the past six months or so, Margo has experienced an exacerbation of what she assumes are symptoms of her M.S. -fatique, stumbling and some tingling sensations in both legs. She is terrified. She is in a new relationship with a co-worker and they had been planning to begin living together, which Margo expected to lead to marriage. Since these symptoms have appeared, Margo has lost any interest in sex and in fact has avoided sex with her current boyfriend, citing "female problems". He is now wondering if something is going wrong in their relationship. She also reports resenting her children's demands on her and feels that they are taking her abilities as mother for granted. She has not talked to anyone about her situation, including Dr. Kiley and dreads diagnostic confirmation that her MS is now becoming active. Margo also revealed that three days ago a home pregnancy test was positive, and she is contemplating an abortion.

Background Information

Margo is currently in an intense intimate relationship with William, a 47 year old partner in the firm that employs her. He is divorced and has two children in college. The relationship has been going on for two months, and she describes William as affluent, capable, sensitive, and very much in love with her. "He loves the part of me he knows, which is me at my best and the part that always comes out when I’m with him -at least until recently". They have discussed marriage, but want to try living together first. "Both of us were in terrible marriages and never want to go through that again, my first husband was abusive and his wife was an alcoholic".

Margo is the third of 5 children. Her parents live 500 miles away in a small town and rarely see her, although they fly their grandchildren out annually during the summer. Margo attributes her emotional distance from her parents as occurring in adolescence. "I was pretty wild and got pregnant early, I think they still think of me as the one they failed with". Her father was a prominent pediatrician in community, and he regarded Margo’s pregnancy during her freshman year in college as a personal humiliation. Although she married the father of the baby, the marriage lasted only two years. Her other child was the result of a brief love affair, and there is no contact between Margo’s son and his biological father. "My Dad and Seth are close, and I am very grateful for that. He and Mom seem to love Chrystal also, but it seems more qualified".

Margo’s older brother, Michael" died at age 36 from AIDS. Like his father, he was a physician. Margo knew her brother was gay years before her parents did, largely because Margo was Michael’s sole confidant in the family. Michael did not reveal his sexual orientation to his parents until he was a few months from death. Margo feels that her parents still regard her knowledge of Michael’s sexual orientation as a betrayal. According to Margo all the other kids did pretty much as expected: went to college, married and moved back to town. Her younger brother Rob (34) is a city engineer, her younger sister Deb (32) is a middle school teacher, and Dan (32) is a real estate attorney. "Nobody does drugs, nobody gets depressed, and they all get together and lament about Michael and me". Margo describes Michael’s death from AIDS as the biggest loss in her life, "He was the only one in the family who loved me for who I am, trusted me, believed in me, and understood that bad things happen to good people. Michael helped me complete college, and also helped me to buy my house...maybe he saw this coming, wanted to give me some happiness for awhile".

When asked about whether her family knew about her current relationship, Margo again became tearful, and said that she had told them she had met someone special and really solid and that they would like him. "William is a classy guy, like Michael but not like him. He is as smart as any of them, loves me, and I guess felt that if William marries me I could go home again with my head held high. Now I’ve blown it again, proved them right. They can spend the rest of their lives apologizing about me. They’ll wonder why Seth and Chrystal turned out as they have -not that I could possibly have anything to do with that".

At this point Margo is unclear about what to do next. She feels she should pursue a diagnostic evaluation of her symptoms, but can’t bring herself to do it. She hasn’t been able to concentrate at work, and now several projects are falling behind. "I can’t hold this together much longer, Seth and Chrystal are bickering and I think it’s the tension and my resentment of their needs. William is beginning to wonder about whether he’s bet on a lame horse and I guess I’m feeling that too. If we end our relationship, that end of my job -its too small a place and I don't think either of us could bear his anger. Anyway, I’m not sure even I can survive this. I know Mom and Dad would take Seth and Chrystal if something were to happen to me".

Summary and Intervention Plan

At this point Margo is still undecided pursuing a diagnostic work-up of her symptoms, and doesn't feel ready to discuss her symtoms and fears with William. She denies suicidal feelings, despite my expression of concern. We agreed that she would return for an appointment next week and that she would call the clinic for an emergency appointment if need be.

 Case URL

http://catalyst.washington.edu/webtools2/pbl/index.cgi?owner=mukboy&id=100