Clinical Assessment


Dateof Assessment:


Client’sbackground information

EdwardS. is living his dream life that he had admired for a long period. Hewished to be sober one day and restore back his family ties that hehad destroyed when drug addiction had taken over him. Currently, heis undertaking his senior master classes at Cal State Northridge,majoring in kinesiology. He stays with his brother who owns a physictherapy clinic, at the same time, he works for his brother as a wayof acquiring knowledge and experiences for his practical lessons.Upon completion of his senior masters’ classes, he aims to get hisPh.D. as a physical therapist.

Edwardwas taken to the Malibu Beach Recovery Center in August 2011, veryinsane at mind and had lost his job and social support from hisfamily. He is bitter and insults everyone who comes his way includinganimals and pets. Edward describes how drug addiction robbed him hisrelationship career and family social support. He expresses concernsabout losing his identity and worthiness and the inappropriateness ofthe previous treatment. He seems shaky and unstable before hisattendant who promises him that everything will be settled.

SubstanceUse and Treatment History

Mr.Edward describes his first encounters with drugs to be back in thejunior classes when he engaged peer groups that used drugs widely. Heoutlines the sequences in which he used to take more beer and drugsthat made him lose his sobriety and focus on life. Previously, Edwardhad tried to withdraw from drugs, but his condition got worse withtime. As a result of drug withdrawal, he started becoming rude topeople and animals, being easily agitated and irrational. He goesahead to state that his reasoning was not logical at all due toinsane thinking.

Uponhis arrival at the Malibu Beach Recovery Center, Edward could not gofor six hours without using drugs. As a result, he used to overdosehis prescriptions because he badly wanted to recover his self-loveand uphold his self-standards. Initially, he was prescribedmedications that lasted him six weeks. However, he states that hiscondition worsened and felt too sick. None of his family members iseither a heavy drinker or an addict of any drug that has caused themany social problem.

Hedescribes how stressed he has been for the last six weeks when heattempted to solve his condition without any success. He admits thathe continued to take more drugs because no medication was working forhim. The effects of his substance abuse are inclusive of memory lossand poor organizational skills. This is because a continued use ofbenzo`s and oxy without taking breaks can cause a significantconfusion of addition. Edward also used some mild painkillers thathelped him when he experienced severe headaches. Benzo withdrawalprocess thus worsened his situation.

Socialand family history

Edwardhighlights his family when he mentions his brother and his father. Hedescribes how disappointed the parents are because of his drug andsubstance use. His relationship with his family has been destroyedsince no one wished to be associated with him due to his rudeness andweird behaviors. After his family had noticed that his addiction hadtranspired to Suboxone and Klonopin, they took him to a chemicaldependency specialist who would regulate his drug use and make himsoberer. However, he has not been admitted with any blood and sugarlevels fluctuating conditions

InterpretiveSummary &amp Diagnostic Impressions

Mr.Edward was administered with Addiction to Opioids and Benzos that isassociated with high drug abuse and alcohol use disorder. Hedemonstrates tolerance to medicines, withdrawal, participation inrude behaviors and continued drug and substance abuse. Mr. Edward hasa great urge to stop using drugs to be sober and begin thinkinglogically and sane. He dislikes his irrational thinking that hasaffected his character and identity. His ongoing social addictionfrom Opioids and Benzos have contributed to his insanity


350.90 Alcohol Use Disorder – High

305.1 Caffein Use Disorder – moderate

V62.29Occupational health problems

V60.29social problems

PreliminaryTreatment Plan

Followinghis continued drug abuse, Mr. Edward has been recommended to seek analternative treatment procedure within the Malibu Beach RecoveryCenter where chemical specialists will carry an investigation toachieve his appropriate medical prescription. A detox program thatwill last for six weeks was also recommended to help him control hisemotions when overwhelmed and gave him space to think properly. Yogaexercises had also been highlighted to be a useful tool in diagnosinghis condition. Upon his discharge, Edward will be a transformedindividual who will be able to gain mental control over his emotionsbe focused and think well

Uponcompletion of his treatment, Edward will be able to reunite with hisfamily and became somebody in the community where he lived. Addictionto Opioids and Benzos can thus be monitored through a regular checkby a physical therapist.