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The Assignment Part 1: Comprehensive Client Family Assessment With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations): Demographic information Presenting problem History or present illness Past psychiatric history Medical history Substance use history Developmental history Family psychiatric history Psychosocial history History of abuse/trauma Review of systems Physical assessment Mental status exam Differential diagnosis Case formulation Treatment plan Part 2: Family Genogram Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents). reference 4
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Assignment2: Practicum – Comprehensive Assessment of Clients
Demographic Information:
CO is a 24-year-old African American male, the patient noted that his father is of African descent while his mother is from the Caribbean Islands. CO is single who lives alone in a rented apartment until about two weeks ago when he was evicted from his apartment after he lost his job. Patient states he has since been homeless, and no support from his family. Pt states “I feel betrayed by my family, especially my mother and brother, who both refused to help me. That hurts, and makes me feel very depressed.” This is patient’s first admission to the hospital psychiatric unit; he was referred for individual therapy by his psychiatrist because he has been staying in his room and not attending therapy groups on the unit.
History of Present Illness:
CO explained that he has been feeling very depressed recently after he lost his last job at the convenience store, and unable to get a replacement. He stated that things got worse after he lost his apartment, he reached out to his mother and brother for help, but they both abandoned him. CO stated that he became homeless, hopeless and helpless, states “I feel lost and empty after my family abandoned me, that l tried to kill my self with a knife”. Patient present to the hospital with self-inflicted abdominal wound, after pedestrians who saw him stabbing himself called 911. He was then transferred from the ER to the hospital psychiatric unit for evaluation, under a mental health emergency detention warrant.
Psychiatric History:
CO admits a long history of depression after finishing high school, he said he started seeing a psychiatrist about 3 years ago, and was recently placed on Seroquel and another medication that he stopped taking about 10 months ago (patient cannot remember the name of the medication). He states the medications does help him for his anxiety and paranoia feelings that people are against him. CO states he stopped taking the Seroquel about a month ago when he started noticing himself having a smirk on his face, which appears like him smiling inappropriately. This patient attributed to being a medication side effect he did not like.
Medical History: Patient is in good health with no medical history.
Past and Current Medications: Seroquel 100mg at bedtime; another psychotropic medication that patient stopped taking 10 months ago. Current Medications are Ambien 10mg at bedtime, Remeron 15mg po at bedtime
History of Substance Use and Abuse: CO admits a history of alcohol and marijuana use from age 19, states he has since stopped abusing alcohol and marijuana for the past two years. Admits smoking cigarettes said he has not smoked cigarette for about a week, but willing to quit.
Developmental History: CO states he grew up with one other sibling, in a loving family of 4. States he use to be shy in high school and has few friends
Family History: CO’s father died two years ago, at age 57 from heart attack. His mother is 53 has a history of hypertension that is well managed with medication. His parents or brother has no psychiatric or substance use disorder.
Social History: CO is currently homeless, with no job, states he has been trying to get another work after losing his job about a month ago and evicted from his apartment. Patient has no health insurance or any friend to talk to except his mother and brother, that he now said have betrayed him, by not helping him through his financial difficulties. CO states that he has been sleeping at homeless shelters and getting hot meals from church organizations. He said, “Life has been very rough for the past month”.
Trauma History: CO states his father was very strict with him while growing up, and was physically abusive, by flogging him with sticks when he does something wrong. He said these abusive events has always played in his mind over the years. CO has no current access to a gun or weapon.
Psychiatric Review of system (ROS): CO is alert and oriented to person, place, time and situation. Patient noted to have a flat affect and decreased energy, laying in bed most of the day, not interacting with peers or attending any group. He expressed a feeling of being hopeless and helpless but currently denies suicide ideations, hallucination or delusions.
Mental Status Examination (MSE): CO is well groomed, dressed appropriately in hospital paper scrubs. Speech is clear but hesitant, behavior and psychomotor activity are intact. Pt appears depressed with flat affect, logical thought process, cognitive is intact, and patient is a good historian. CO’s insight is intact, and his near and far memory are intact.
Differential Diagnosis: According to the information provided, clinical history, and symptoms described by CO, the following DSM 5 diagnosis may be found appropriate for this patient:
a. Major Depressive Disorder, Recurrent.
b. Depressive Disorder NOS
c. Adjustment Disorder with Depressed Mood
Case Formulation: CO is a 24-year-old single African American male, who was admitted to the unit after feeling depressed and stabbing himself on the abdomen, due to the stress of loss of a job, being homeless, and feelings of being abandoned by family. Patient states he felt “sad, lost and empty”.
Treatment Plan:
Patient will be compliant with his current prescribed medication
Obtain urine and draw blood samples for urinalysis, UDS, CBC, CMP, RPR, and Lipid panel.
Patient will attend daily unit group sessions and scheduled individual therapy
Family therapy to obtain more collateral information and resolve conflict.
Provide patient information about support, self-help groups or organizations that can be of assistance to him after discharge from hospital.
Patient will use self-affirmation and distraction techniques when stress and anxiety are heightened.
Genogram for Patient CO.
A genogram is the graphic representation of a patient and several generations of his or her family. It is a very useful tool for the assessment of individuals, couples, and families; and should be a routine part of a comprehensive patient or family assessment (Wheeler, 2013). It can help understand key people and relationships in a client’s life, see patterns within those relationships and generational patterns that are affecting a client (Garth, 2016).
Three Generational Genogram for Patient CO
Adam (Brother)
CO
Grace (Grandma)
KO (Mom)
CO Snr. (Dad)
Victor (Grandpa)
Sarah (Grandma)
Phil (Grandpa)
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Washington, DC: Author.
Garth, A. (2016). What is a genogram and why do l need to learn how to create one? Retrieved from
https://www.socialworkhelper.com/2016/09/14/genogram-need-learn-create-one/
Wheeler, K. (2014). Psychotherapy for the advanced practice nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.