Instructions for Use of this Training Simulation
This document provides a case story containing relevant fact patterns used by reviewer trainees when learning how to apply Clinical Reasoning and Case Formulation strategies to a case-based situation. The case simulation involves a man named Mateo who is served for serious physical health issues, substance abuse, and mental health needs. Details are provided through documents reflecting information in his chart and conversation with providers. Your task is to organize and rely on the available information to complete the organizers and tools provided for building a strong Clinical Reasoning and Case Formulation process. Some information you would like to have may not be available in a brief written simulation. You and your group can make assumptions as long as you STATE those assumptions for context.
Persons Working with and Supporting Mateo
Nurse Practitioner – Ms. Hernandez CSW and representative payee – Mr. Perez
Therapist – Mr. Gonzalez Psychiatrist – Dr. Gutierrez
Sister- Amelia Ex-wife- Maria and Son- Pepe
Probation Officer–Mr. Robertson
Background Information about Mateo
Mateo is a 47-year-old bi-lingual Caucasian-Hispanic descent. He lives in a HUD Section-8 apartment complex in his own one-bedroom apartment located one block from a bus stop. In the spring of 2018, Mateo began receiving community support and treatment services through a local integrated behavioral health clinic. Over the past three years, Mateo had crisis services for 12 episodes with two substance abuse relapses in the past year — one just over six months ago when he was administered Naloxone by EMTs and that prompted his seeking treatment at a Methadone clinic. He has had prior suicide attempts during depressive episodes and relapses. Other concerning incidents have occurred during periods of extended use—one was a bleeding gash to the back of his head that he could not explain, alcohol poisoning, and a near-death experience following exposure to cold during the winter months of early 2018 when Mateo was homeless, using prescription opioids, and passed out in a park during severe winter weather. Another concerning event occurred when Mateo attempted to rob a liquor store. He did not have a firearm but did have a pocket knife that was considered a weapon, He currently on probation.
During the past year, Mateo has moved from being homeless and suicidal, to a hospital for stabilization. About six months ago with the assistance of a case worker at the Methadone clinic, Mateo was able to secure transitional housing. Cocaine, crystal methamphetamine, heroin, prescription painkillers, and alcohol are his drugs of use, with cycles of recovery and of relapse.
Mateo receives SSDI. He pays some of the child support for his some Pepe. After covering this expenses and paying his rent, he has little discretionary spending money left and visits the foodbank 1-3 times a month. He has applied for a part time job at a hardware store to supplement his income. He attended a barber school in the past but did not complete the course nor receive his barber’s license.
Mateo grew up in a family where alcoholism, child abuse, and domestic violence were present. His first contact with substances occurred at age 12 when an uncle gave him a beer at a family gathering. His father, who suffered from major depression and alcohol addiction, committed suicide the following Christmas. Mateo was present in the home when his father committed suicide by a shotgun blast in the mouth: Mateo was the one to discover his father. Mateo reports still having nightmares about this event. After his father’s suicide, Mateo began drinking once or twice a week, progressing to binging one to two times per month by age 14. He began smoking marijuana at 14, and tried cocaine by age 16. Mateo was able to clean up his senior year to focus on completion of high school and joining the Army. He accomplished both of these goals, completed basic training, and then served in the Iraq War.
Mateo had his first major depressive episode at age 24 following a military action (a fire-fight in a neighborhood) in which he accidentally killed a young boy. There were no charges as Mateo’s unit was under attack. Nevertheless, Mateo was traumatized by the child’s death and not able to forgive himself for killing the child. Disturbing nightmares and flash-backs began at that time and still recur now when Mateo is under stress. He began drinking heavily and failed to report for duty twice during a two-year period due to his substance use. Mateo served in the military for 10 years and did receive an honorable discharge at the end. He was not formally diagnosed with PTSD by the Army. He distrusts the Veteran’s Administration (VA) and so has received no services from them.
Until five years ago, Mateo was a truck driver for a chain of big-box stores. This job ended following a heart attack suffered while driving a truck on the job. Mateo admitted that during his time as a truck driver he was using a lot of stimulants, including methamphetamines. He would use painkillers and benzodiazepines to help him sleep when he was not on a drive. Mateo continues to suffer periodic angina pains. Until a month ago, Mateo has not been willing or able to follow through with regular medical or dental care. He has just begun treatment at the local FQHC and has just had a thorough physical and lab work done for the first time in years although he has not yet been scheduled for a dental examination. He has been back for a second visit to discuss lab results and a plan. Mateo’s Primary Care Provider (PCP) who is a nurse practitioner, is concerned with a number of serous issues that have been detected.
Mateo’s Nurse Practitioner reports that the results from his blood work and screening at FQHC indicate that his blood pressure is normally 150/90 and is even higher when he is upset or panicked. His weight, which is elevated for his height, is primarily around his waist and appears to be increasing (he has gained 7 pounds since his first visit). He has low good cholesterol and elevated bad cholesterol/overall cholesterol. She is very concerned about his daily smoking two packs of cigarettes. She has started him on an ACE inhibitor and a calcium channel blocker for hypertension.
Mateo still suffers occasional serious bouts of depression, often associated with times of loss and loneliness in his life. The psychiatrist at the FQHC has been meeting with Mateo twice a month for the past two months. He has prescribed Zoloft and Cymbalta to control psychiatric symptoms. The psychiatrist is now working with Mateo to find the right mix and dosages of medications to achieve maintenance. Mateo reports that Zoloft has some unpleasant side effects, mainly dry mouth, difficulty sleeping and decreased energy which are very distressing to him. He has been titrating Mateo off Zoloft and adding Cymbalta. His primary concern with Mateo is his ability to remain Sober. The nurse practioners is informed of all of Mateo’s treatment modalities.
The frequency and duration of Mateo’s relapses with have diminished. He has been regularly attending AA/NA groups and social and therapeutic activities at the mental health center. Six months ago Mateo started receiving services at a Methadone clinic for addiction to heroin and prescription pain pills. MAT treatment was at the recommendation of a behavioral health provider and Mateo’s sister, which he has a high degree of trust in. He receives methadone each morning from a clinic and is receiving 110mg daily everyday except Sunday as the clinic is closed. Mateo accesses medical transport to and from the clinic.
Present services include: primary health care from the FQHC, medication management, MAT, CSW services, substance abuse group therapy, HUD housing with on-site support available, AA/NA groups with a sponsor (he has been working a 90-day/90-meeting strategy), and representative payee services. Mateo’s services are currently provided by several agencies. Mateo presently receives SSDI income, HUD housing, food stamps, and a bus pass for transportation other than to the Methadone clinic.
Screenings and Diagnoses
Health Screenings Performed:
Height and weight Blood pressure Smoking assessment
Substance assessment ASAM PHQ 9 for depression
Results of Screenings:
– Weight elevated for height – Weight primarily around waist
– LDL high, HDL low and overall high (HDL-35, LDL-180, overall-250)
– Thyroid values in normal range – Glucose in normal range
-Regular blood work for Methadone – High blood pressure – 150/90
– Obesity – Dyslipidemia – Hypertension – Opioid Use Disorder
Behavioral Health Screenings Performed:
Bex Depression Scale Trauma Screening Questionnaire (TSQ)
Substance assessment – ASAM Bio-Psycho-Social assessment Psychiatric evaluation
– Major Depressive Disorder, recurrent, moderate – Post Traumatic Stress Disorder
– Alcohol Use Disorder – Stimulant Use Disorder – Opioid Use Disorder
Mateo has three children ranging in age from 17 to 4 years of age. He has a good relationship with his youngest son, Pepe, who is four years old, but Mateo does not have contact with his other children. As a provision of a visitation agreement, Mateo is having unsupervised visits with his son in his apartment. Recently, Maria, his former wife and mother of Pepe, has reappeared in his life. She and his sister, Amelia, are actively providing encouragement and support to him at this time. He speaks with his former wife, Pepe, or his sister nearly every day.
Mateo attends a local church. Until about two months ago Mateo’s church attendance was sporadic and inconsistent. More recently he has allowed his sister to accompany him to church twice a week, and he is finding some comfort in attending again. The church hosts AA, NA, and recovery-oriented Bible study groups several times a week and Mateo has been attending at least one of these groups each day for the past three weeks.
The personal statement from Mato includes the following aspirations: “I want to live a life free from drugs and alcohol. I want to be a good father to Pepe and to reconnect with my older children. I want to work again and make a decent living.”
Mateo’s Interests and Life Plans
Mateo has three children ranging in age from 17 to 4. He has a good relationship with his youngest son, Pepe, who is the four year old, but does not see his other children. As a provision of child support arrangements, Mateo is having unsupervised visits with his son in his apartment. Recently, Maria, his former wife, has reappeared in his life. She and his sister, Amelia, are actively providing encouragement and support to him at this time. He speaks with his estranged wife nearly every day and his sister has been taking him to church twice a week. The church hosts AA, NA, and recovery-oriented Bible study groups several times a week. Mateo has been attending at least one of these groups each day for the past three weeks.
Mateo lives in a minimally furnished apartment that contains many snap-shots of him and his four-year-old son, Pepe. He stated that right now, Pepe is the most important thing in his life and said, “I want to do better this time, use the lessons I have learned and be a better father. Pepe is my reason for getting and staying sober.” He sees Pepe, twice a week — Wednesdays and Saturdays — for three hours at his apartment. They are not yet having overnight visits but hopes to be able to do so soon.
Mateo shared his work history and said that things were going well until his heart attack. “I had a steady job, I was managing my addictions, had a great relationship, and then — BAM! I start having chest pains on the job and slumped over while driving my usual delivery route. Lucky thing I was at a stop and some nice folks with cell phones called for an EMS unit that arrived quickly.”
He went on medical leave and then was not able to return to this job as a truck driver. He stated, “When I couldn’t return to my job, which I loved, things just went downhill from there. I started taking prescription drugs and drinking. My woman left me and things just went from bad to worse.”
Mateo says his biggest challenge is battling loneliness and feelings of loss. He reports that his newly discovered health issues are also now a worry for him, as he wants to be around for his children. He misses having a job, daily routines, and meaningful things to do each day. If he could find a way to finish his study and be a licensed barber, he would jump at the chance. “I called the barber school I attended to see what I needed to complete to get a barber’s license, but no one called me back.”
Mateo reports that his symptoms are generally stable and managed, but he still could get himself into a “dark and scary place” if he sat around his apartment thinking about his life. Feelings of loneliness and loss are major triggers for his binges. He admits to “holding feelings in” lately — feeling that people “don’t really know me. He desires also to fulfill the requirements of probation. He reported he is ashamed of his past, unlawful behaviors from the time he was using. He stated, “I was strung out, desperate , and not thinking about how my actions might affect others”.
Mateo stated that his personal wellness and recovery goals include:
•“Staying clean and sober”.
•Getting my health issues under control to avoid another heart attack or stoke.
•Supplementing my current income with part-time work.
•Fathering my four-year-old son like a real dad.
•Building relationships with my other children.
•Participating in church activities and continuing my spiritual journey to get to a better place in life.
•Connecting with a men’s group for fellowship, support, and accountability.
•Getting a bigger apartment so that Pepe can have stay-overs with me.
•Having a stable relationship with a good woman who doesn’t use substances and who likes me for who I’m becoming.”
He is working on some of these issues with his workers at the agency, and says, “they focus so much on day-to-day sobriety. I need help with that — but I want a fuller, more independent, normal life like other people have.” Mateo would like to get more connected to small groups and individuals in a church community where he feels comfortable and accepted. He has been able to make amends and repair his relationship with his sister, Amelia, and she has been helping him to connect with a spiritual community. He stated, “I am fortunate and grateful for Amelia forgiving me, accepting me, and supporting me. It is truly a blessing.” His mother is still alive and Amelia would like him to reconnect with her, but Marco doesn’t feel ready for that yet.
A New Problem with Possible Adverse Consequences
Mateo just called his therapist today saying that Pepe’s mother has been offered a job promotion that would require her to move to a city about 200 miles away. She must decide within the next week and then move within a month if she takes the job. Pepe will move with her to the new city.
Mateo is shocked and feeling overwhelmed by the possible loss of Pepe from his life. He hopes that Pepe’s mother will bring him to visit Mateo at least once a month. However, such visitation is uncertain and unlikely to Mateo, given the round-trip driving distance (400 miles) plus the travel expenses involved. He said he senses the possible onset of a depressive episode starting to kick in.
Amelia has offered to help Mateo see Pepe if Maria moves away by arranging monthly visits and keeping Pepe for weekend stay-overs and extended summer stays at her home.