Social Work Case Study: A 75-Year-Old Patient

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Case study:
A 75-year-old woman who lives in an apartment building designed for senior living. Recently her neighbors have lodged complaints with the social worker in the building. They state that there are bad odors and roaches migrating to their apartments from her apartment. Her adult son is her primary caregiver and reportedly lives with her but he is not often seen. You are assigned to conduct a comprehensive assessment, make a plan of care and communicate your findings to your supervisor, the physician and those who are authorized to receive information about her care.

1. Your assessment of the patient‘s mental and neurological status, including cranial nerves as you would if you were present in the patient’s home, or bedside.
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Then I would assess my client at first glance to see how they respond to me, upon entering their living space. For example as I enter the room is the client calm, agitated, or lethargic. I would pay close attention to facial expressions, manners, and mood. As I look for the clients reaction I will assess to see how the client appears; for example are they clean and presentable or do they look disheveled, does my clients’ environment have an odor or is the living space clean.
• Mental Assessment
- Assess the client’s level of consciousness to determine if the client has full consciousness, lethargy, obtundation, stupor, or is a coma.
- Assessment of the client’s characteristics of speech, by focusing on the quantity, rate, volume, articulation of words, and frequency.
- I would then assess the client’s mood by asking questions like; how are you feeling today? Or how is your overall mood? I will make sure to assess for depression and if present I will assess for depth and risk for suicide.
- Thought process: I will assess to see if the client can remain organized and coherent through the process of the interview. I would make note of variations and abnormalities in thought process, content, and

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