he Case of Samuel
Intake Date: March 25, 2021
IDENTIFYING/DEMOGRAPHIC DATA: Samuel is a 62-year-old, widowed, African American male. He is unemployed, receives Social Security benefits, and lives on his own in an apartment.
CHIEF COMPLAINT/PRESENTING PROBLEM: Samuel scheduled a meeting with this social worker for increased feelings of depression. Samuel, who was normally articulate, had been appearing confused and slightly disorganized.
HISTORY OF PRESENT ILLNESS: Samuel became depressed and psychotic right after Thanksgiving and had to be taken to an emergency room. He was hospitalized at that time for several days. Samuel was released to outpatient care but was deemed unable to return to work. At that time, he had a diagnosis of major depression with psychotic features. After two other psychiatric hospitalizations, he was gradually stabilized. These feelings were brought on after his daughter moved out of the apartment they had shared for many years to live with her boyfriend. He reported difficulty adjusting to living alone and said he often feels lonely and anxious. He would not get out of bed, thinking he has no interest in anything any longer. Sleep was a great deterrent. He was feeling guilty about interfering with his daughter’s happiness and now thinking he could have done something to extend his wife’s life.
PAST PSYCHIATRIC HISTORY: Samuel denies past psychiatric history.
SUBSTANCE USE HISTORY: No history of alcohol or substance abuse issues are noted, and he had no criminal background or current legal issues.
PAST MEDICAL HISTORY: Samuel has a history of high blood pressure and migraines. Samuel has a positive history of medication and treatment compliance. When asked if Samuel was experiencing any physical health problems he mentioned that he had collapsed in the doctor’s office recently. He reported that he had undergone a number of tests including blood tests, which he thinks were all fine. Medical professionals have always made him nervous and he hates blood tests. He noted that he has high blood pressure but it increases more when he needs to go for testing. He realizes he needs these tests though. It is not uncommon for him to pass out when the nurses need to draw blood. This has happened often over the years. In collateral contact, his daughter verified his recent tests a MRI, CT scan, and EEG tests were negative.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: When Samuel was 7 years old, he was placed in foster care and has had very limited contact with his extended family. Prior to the pandemic Samuel had a steady employment history in food services and retail. Samuel reported his religious background is Baptist, but he is not affiliated with a congregation or church.
Samuel lost his wife to cancer in 2001. He loved his wife and recalls really good times. Back in 1999 he was so happy he believed he was on top of the world. He felt this way for a couple of weeks but then recognized there were some challenges in their marriage as well. Samuel does recall when the marriage was this good, he did not need to sleep like he does now. His wife would get annoyed that he kept her awake since he wanted to talk all night but he indicates he just enjoyed life and needed very little sleep. He was ready to take on the world and developed several ideas to develop businesses. His wife listened but would not participate in any of the business schemes. She would get annoyed since he was not focusing on his regular job. He wanted to make a great life for her but sadly she was diagnosed with cancer.
CURRENT FAMILY ISSUES AND DYNAMICS: Samuel has minimal peer relationships, choosing not to socialize with anyone except his daughter, with whom he is very close. Samuel raised his daughter as a single father after his wife passed away. Melissa is 28 years old and works as an emergency medical technician (EMT). He reported during sessions with his social worker that he speaks to his daughter frequently, and although she only lives 10 blocks away, he misses her terribly.
MENTAL STATUS EXAM: Samuel was neatly dressed and looks his stated age. His mood is depressed, and he lacks eye contact. His affect is anxious. Motor activity is appropriate. Speech is clear. Thoughts are logical and organized although there seems some confusion at times. There is some evidence of delusions and hallucinations in discussion with Samuel. On formal mental status examination, Samuel was oriented to three spheres.