1. Reggie has come to see you "because my wife told me I had to."  Reggie has had significant memory problems in the past 6 month.  Initially it was forgetting names and improtant dates such as his wife's birthday but last week he could not even remember how to get home from the grocery store.  Reggie is only 40 years old.  He was a professional football play and has been dealing with what doctors call Post concussion syndrome for years.  He retired from football at age 32.  He has had some short term minor memory lapses but has also had some issues with significant mood swings.  He has been diagnosed with Bi-Polar Disorder but his doctor recognizes that his mood swings can be related to brain damage and/or his substance use.  Reggie used steroids, cocaine, and alcohol when he was playing football.  He stopped the cocaine and steroids when he stopped football.  He continues to drink 8-12 cans of Miller High Life daily.  He has minor withdrawal symptoms when he does not drink for a day.  He informs you that he is concerned about his memory and was genuinely scared when he got lost last week.  He is being very open in the initial assessment and discloses that his life is a mess.  He is embarassed by his figure and says he is 50 pounds over weight.  He claims he has always been large but was proud when he was in shape.  He said he use to be able to bench press 350 pounds and squat 400 but now he has problems walking up a flight of stair without losing his breath.  Reggie said that he has no direction in his life and is often just doing meanial tasks that his wife asks him to do daily.  Reggie would like someone to talk to simply to process his feelings.  He also wishes to rebuild some of the connections he had with the football players he use to play with.  He loves his wife and is concerned she will leave him because "I am losing my mind."  He enjoys his Miller High Life but also recognizes that he is drinking more than he needs to.  He also thinks that the alcohol controls his mood swings and helps him with his ruminating and negative thinking.  He is opposed to taking medications and has been refusing them for years because he is afraid of the side effects.  His doctor wants him to take a high blood pressure medication, a cholesterol reducing medication, and a mood stabilizer.

1. What are the problems that Reggie has identified so far?

 

2. What are possible diagnoses to consider for Reggie?

 

3. List at least one long-term goal for each problem you would encourage Reggie to achieve based on the identified problems in question #1.  

  

4. List at least 3 short-term goals in a SMART format that you believe Reggie can achieve in the next week.

  

5. What are three questions you would ask Reggie to help him begin developing his own individualized goals for his treatment plan?

 

6. What are some services that you would refer Reggie to?

  

7. What criteria would you like to see met from Reggie before he would be discharged from your services?

Answer rating: 100% (QA)

1 Identified Problems Significant memory problems including forgetting names and important dates Difficulty remembering how to get home from familiar ... View the full answer