Instructions
Review the fictitious case study below. You are the hospital social worker at the emergency room, and you are asked to complete a quick assessment of the patient and to report your findings to the staff physician. Based on this scenario, complete the following:
Case Study
At 9:35 p.m. on a Friday night, Juan, age 66, walks into the emergency room of a large metropolitan hospital. He is disheveled and speaking broken English, mixed with Spanish. He is grabbing his stomach in pain and stating “It hurts. Why?” He reeks of body odor and possible alcohol. The nurse, who brings him back to an empty ER room, is met with hostility by Juan. He pushes her away and states, “Don’t hurt me, too.” The nurse turns to you and asks you to try to obtain information from the patient as she rushes to another room to assist with a car accident victim who was just brought in by paramedics. You ask for the hospital interpreter but are told she is unavailable at this time as she is with another patient. Reluctantly, you attempt to question Juan using what little Spanish you know, along with using hand gestures. Juan continues to talk in a confused state as he holds his stomach and moans. He eventually hands you his wallet and inside you find a state ID, no insurance card, three dollars, and a business card of a case manager who works at a local homeless shelter. You point to the card and ask, “Do you live here?” He nods yes. You call the number but reach a voicemail as it is after hours. You ask, “Family?” and Juan shakes his head no and states “Mexico.” He then turns and starts speaking rapidly in Spanish as if he is talking to someone he sees in the room. You turn in the direction he is speaking, but you see no one.
Assignment
Tasks
Write a Biopsychosocial-Spiritual Assessment of the client that includes:
1. A brief description of the patient’s chief complaint.
2. Assessment of the patient’s safety needs.
3. Assessment of the patient’s presenting mental status.
4. A review of the patient’s tangible resources (insurance, financial, housing, basic needs).
5. A review of the patient’s social and emotional supports.
5. Necessary standardized measures that you utilized with the patient.
6. Explanation of your observations and assessment of the patient, including any appropriate notes on transition and discharge planning.
In contemporary health care settings, particularly in emergency rooms (ER), the role of social workers is crucial for providing holistic patient care. Social workers are tasked with assessing patients not only from a medical standpoint but also from psychosocial, spiritual, and environmental perspectives. Such comprehensive assessments aid in developing effective treatment plans, understanding patients' needs beyond the physical, and addressing underlying social determinants of health. This essay explores the fictitious case of Juan, a 66-year-old man who presents to the ER with severe abdominal pain, confusion, and signs of possible alcohol use. The essay provides a thorough biopsychosocial-spiritual assessment, incorporating an analysis of Juan's chief complaints, safety, mental status, tangible resources, and emotional and social support systems. It also discusses standardized assessment measures that could be used, as well as the critical observations necessary for Juan’s transition and discharge planning.
Juan presents with severe abdominal pain, which he expresses through non-specific verbal complaints like "It hurts. Why?" and physical actions such as clutching his stomach. His disheveled appearance, poor hygiene, and the odor of alcohol contribute to concerns about chronic health neglect and substance use. His pain could be indicative of various medical conditions, including gastrointestinal issues (e.g., ulcers, liver disease, or pancreatitis), alcohol-related complications, or even an acute medical emergency. Moreover, Juan’s limited English proficiency complicates communication and understanding of his symptoms, and he appears confused, possibly hallucinating, as he speaks to someone not present in the room. This case requires immediate assessment of his medical condition, but the presence of underlying social and psychological issues necessitates a broader biopsychosocial-spiritual approach.
A primary concern in this assessment is Juan’s immediate and long-term safety. His hostile behavior toward the nurse (“Don’t hurt me, too”) raises concerns about his mental and emotional state, as well as the possibility of past trauma or abuse. Additionally, his confusion and apparent hallucinations—speaking to an unseen figure—indicate potential cognitive impairment or substance-induced psychosis. These factors necessitate careful monitoring, as Juan may pose a risk to himself or others.
In assessing Juan's safety, it is essential to consider both medical and environmental risks:
Therefore, it would be prudent to recommend a psychiatric evaluation in addition to medical care, possibly involving a consult with a psychiatric liaison service. Juan’s confused state might also be linked to untreated delirium or dementia, which could increase his vulnerability.
Juan presents with several indicators of impaired mental status:
Confusion and Disorientation: His confused state, speaking rapidly in Spanish and hallucinating, suggests cognitive impairment. This could be due to several factors, including:
Hallucinations: Juan appears to be responding to internal stimuli, as he speaks to someone who is not there. This symptom could point to a psychotic disorder or substance-induced psychosis.
Emotional Distress and Possible Trauma: His fear of being hurt by the nurse may indicate past trauma or abuse, potentially related to experiences of homelessness or other hardships. Trauma-informed care principles would be essential in this context, where Juan’s aggressive defense mechanisms may stem from deep-seated fears.
Given these factors, it is essential to perform a mental status examination (MSE) focusing on:
The lack of insurance, minimal cash, and homelessness are major social determinants affecting Juan's health outcomes. His wallet contains only three dollars and no insurance card, which confirms his lack of financial resources. The business card for a case manager from a local homeless shelter suggests that Juan may be connected to some social services, but the fact that he continues to experience homelessness implies limited effectiveness of such support. These factors significantly hinder Juan's access to consistent healthcare, stable housing, and basic needs such as food and hygiene.
Juan's housing insecurity has direct implications for his health. Homeless individuals are at a higher risk for chronic medical conditions, substance abuse, mental illness, and victimization. The transient nature of homelessness often leads to episodic healthcare use, particularly in emergency settings, rather than preventive care. Moreover, without insurance, Juan may struggle to access necessary medications or follow-up treatments after discharge, exacerbating the cycle of poor health and emergency room reliance.
Juan appears to have minimal social and emotional support systems in place. When asked about family, he shakes his head and mentions “Mexico,” indicating possible estrangement from family members or geographic barriers that prevent contact. This sense of isolation can contribute to emotional distress, feelings of hopelessness, and exacerbate existing mental health conditions. Social support is a critical factor in recovery from both physical and mental health crises, and the absence of a support system complicates discharge planning and long-term health management.
The business card from a homeless shelter case manager suggests that Juan may have some connection to local social services, but the efficacy of this support is unclear. It is important to explore whether Juan has any community ties beyond the shelter, such as friends, other residents at the shelter, or religious or cultural groups, which might offer emotional or material support. However, the fact that Juan is in the emergency room without assistance and appears disheveled implies a breakdown in whatever support system he had.
A spiritual assessment could also be valuable. Juan may have spiritual or religious beliefs that could serve as a source of strength during this crisis. His hallucinations or speaking to unseen entities may reflect a deeply held spiritual belief or practice, particularly given his cultural background. Engaging in culturally sensitive spiritual care could provide Juan with comfort and help address some of his emotional needs.
In Juan's case, several standardized tools can be used to evaluate different aspects of his health:
Alcohol Use Disorders Identification Test (AUDIT): Given the smell of alcohol, this screening tool can assess the extent of Juan’s alcohol use and whether he meets the criteria for alcohol dependence.
Mini-Mental State Examination (MMSE): This cognitive assessment tool helps to evaluate potential cognitive impairments like dementia or delirium. Given his confusion and hallucinations, the MMSE can provide insight into his cognitive functioning.
Trauma Screening Questionnaire (TSQ): Given his fearful and hostile response to the nurse, this tool could help identify whether Juan has experienced recent trauma, particularly if he has been a victim of violence or abuse as a homeless person.
Beck Depression Inventory (BDI) or Patient Health Questionnaire-9 (PHQ-9): These tools can screen for depression, a common comorbidity among the homeless population and those with chronic health problems.
CAGE Questionnaire: This brief screening tool could quickly assess whether Juan may have an alcohol problem, given his apparent inebriation.
Based on the information gathered, Juan presents with a multifaceted health crisis that includes physical pain, possible substance abuse, cognitive impairment, and psychosocial stressors such as homelessness and isolation. His physical pain may be related to alcohol use, which could contribute to gastrointestinal issues like gastritis, ulcers, or pancreatitis. The confusion, disorientation, and hallucinations raise concerns about mental health conditions, potentially exacerbated by alcohol use or cognitive disorders like dementia.
Juan’s presentation also points to a deeper layer of emotional trauma. His reaction to the nurse’s touch (“Don’t hurt me, too”) suggests a possible history of violence or abuse, either during his time in the shelter system or in previous contexts. His fear and aggression may be defense mechanisms that have developed from a long history of neglect or mistreatment.
From a biopsychosocial-spiritual perspective, Juan’s health challenges are not limited to his immediate medical condition. His homelessness, isolation from family, lack of insurance, and possible substance abuse all contribute to a cycle of vulnerability. This necessitates a treatment plan that integrates medical care, psychiatric evaluation, and social support services.
For Juan’s transition and discharge planning, several key components must be addressed:
Mental Health Support: Engage psychiatric services to evaluate Juan’s mental status thoroughly. This assessment should focus on potential cognitive impairment, substance use disorders, and any underlying mental health issues such as anxiety, depression, or trauma-related disorders.
Substance Use Treatment: If alcohol use is confirmed, it is crucial to refer Juan to substance use treatment programs, such as detoxification or rehabilitation services, that can provide him with the necessary support to address his addiction. Given the risks associated with alcohol withdrawal, a medically supervised detox program would be ideal.
Social Services Coordination: Contact the case manager at the local homeless shelter to discuss Juan's situation. Collaborate on a care plan that includes housing support, access to food resources, and any necessary referrals to social services, including community health clinics that might offer sliding-scale fees or free services.
Family and Social Support: Explore options to reconnect Juan with any family members in Mexico, if possible. While he may not currently have contact, some outreach may provide emotional support and connection. Additionally, help Juan find local community resources, including support groups or peer networks, that can provide social interaction and support as he transitions out of the emergency room.
Education and Resources: Provide Juan with educational materials regarding his health conditions, substance use, and available resources. Ensure that he understands the importance of follow-up care and how to access it, particularly if he is discharged without immediate housing.
Follow-Up Appointments: Schedule follow-up appointments with primary care and any necessary specialists, such as a gastroenterologist or psychiatrist, before discharge. Ensure that Juan knows how to get to these appointments and has a plan for transportation, if possible.
Cultural Sensitivity: Ensure that all interactions with Juan are culturally sensitive, recognizing the importance of his background and language. If an interpreter is available, utilize this resource to facilitate better communication.
Spiritual Care: If Juan expresses interest in spirituality or has specific beliefs that may provide him comfort, coordinate with spiritual care services to offer him support in this area.
In summary, Juan's case presents a complex interplay of medical, psychological, social, and spiritual needs that require a comprehensive biopsychosocial-spiritual assessment. His severe abdominal pain, confusion, and possible substance use highlight the urgent need for immediate medical intervention. However, it is equally critical to address his broader social determinants of health, including homelessness, lack of social support, and the potential for trauma. The assessment should guide the development of a holistic care plan that encompasses medical treatment, mental health support, substance use interventions, and coordination with social services.
This approach not only addresses Juan's immediate health crises but also lays the groundwork for ongoing support and recovery. By adopting a comprehensive and empathetic framework, social workers can play a pivotal role in ensuring that individuals like Juan receive the holistic care they need to navigate their health challenges and improve their quality of life. Ultimately, the goal is to help Juan regain stability, access necessary resources, and foster connections that empower him to build a healthier, more resilient future.
Copyright © 2012 - 2025 Apaxresearchers - All Rights Reserved.