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Nurs 6640 Week 3 Assignment
Part 1: Comprehensive Client Family Assessment
With this client in mind, address the following in a Comprehensive ClientAssessment (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).
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Nurs 6640 Psychotherapy Individual Sample Solution
Introduction
A comprehensive client assessment includes the patient’s medical, socio-economic, and family history and a detailed physical examination. As stated by Forbes & Watt (2015), this process helps a mental health practitioner identify potential health issues that positively and negatively influence a client’s health. Based on a practitioner’s findings, he/she can make an early diagnosis, prioritize care and influence immediate interventions for the issues identified.
Part 1: Comprehensive Client Family Assessment
Demographic information
For this comprehensive assessment, the family of the client is comprised of three members. The first is a 15-year-old teenage girl who is accompanied by her parents. Her father is 40 years old and her mother is 35 years old. Though her grandparents were born in the United Kingdom, both the client and her parents were born and live in the United States. They are all Christians.
Presenting problem
The parents had been referred to the clinic for a psychiatric evaluation from the emergency department following concerns by the parents on how the child‘s behavior had changed over the past few months. According to her mother, her daughter had changed from being jovial, outgoing, and enthusiastic to being socially withdrawn and generally having a sad mood. Recently, she reportedly showed no interest in things that she previously loved doing. Although the father was silent as the mother spoke, he nodded along to the mother’s reports as a sign of agreement with the information that was provided by the mother (Silverman, Kurtz & Draper, 2016). The girl was taken to the emergency department when her parents discovered that she had cut herself in the wrist and ankle. Upon receiving medical treatment and discharge, she was given a follow-up referral to the clinic for further evaluation and treatment.
History or present illness
The client reported that the issue started some two months ago when some schoolmates made fun of her and her physical appearance and verbally insulted her. She was threatened to be roughed up and be thrown in the garbage if she shared with anyone about it. Although her mother gave her a lot of emotional and psychological support, she was frustrated that her father thought she was being too childish by telling her how sensitive she was becoming with little issues and urging her to ignore the schoolmates who harassed her. McGrath (2014) notes that this is likely to affect parental relationships with their children, the same way the client admitted that it was her father’s attitude on the entire issue that increased her disappointment and felt bad each time she saw him.
Past psychiatric history
The client had no previous psychiatric illnesses. However, she understood that her grandmother had a history of depression and social phobia. However, she was not aware of any other close or distant family members who had known psychiatric illnesses.
Medical history
The client informed that she was diabetic and was using insulin. Her mother had type 2 diabetes mellitus that was well controlled with medications, diet, and exercise. Her father had a history of hypertension which was well controlled with medications. The father is on amlodipine 10mg once daily.
Substance use history
The client denied any use of illicit drugs. Her mother often consumed 2-3 glasses of wine weekly but denied the use of illicit drugs. The father reportedly drank4-5 beer cans weekly, especially over the holidays and weekends.
Developmental history
The client achieved all the developmental milestones at the appropriate ages.
Family psychiatric history
According to the father’s report, growing up in an environment that was not conducive to his father who was a heavy drinker and was always detached from the family was difficult. However, none of his family members had a known mental illness. On the other hand, the client’s maternal grandmother had been diagnosed with anxiety and depression.
Psychosocial history
The client stays with her parents and is a junior high school student. She plays table tennis and is an active participant in community initiatives and teen activities in the church. Although she has several friends from the surrounding neighborhood as well as school, she hasn’t been socializing with them as she previously used to. Both the parents and the client informed that they received adequate support from friends and family. Her mother is an elementary school teacher while her father is a human resource manager in the local textile industry.
History of abuse/trauma
The client denied any emotional, physical, and sexual abuse within and outside the family. However, she reported verbal and emotional abuse from colleagues in school.
Review of systems
Generally, the client is up to date with her annual immunizations.
EENT: the client wore corrective lenses, denied problems in hearing, had an intact sense of smell, no breathing problems, and could easily chew or swallow.
Head & Neck: The client denied having a head injury, the head was regular and symmetrical, the trachea was midline with no deviations noted and no lymph node was palpable.
Respiratory: the client had clear bilateral lungs, normal breathing sounds, and a normal and regular respiratory rate.
Cardiovascular: the client denied any chest pains, and no heart murmurs; the pulse rate was normal and regular.
Gastrointestinal: the client denied any bowel issues; bowel sounds were present in all quadrants, denied diarrhea and constipation.
Genitourinary: the client denied pain in micturition and blood in the urine.
Musculoskeletal: The client moved all extremities without complaints of joint pains. She also had a normal gait.
Physical assessment
The neurological exam revealed that the client was alert and oriented in time, place, and person. In assessing the cranial nerves, CNI (olfactory) revealed that the clients’ sense of smell was intact and could differentiate the different types of smell. CNII (optic) revealed that the clients’ visual acuity was 20/35 on the Snellen chart, CNIII, CN IV, and VI were intact. CN V (trigeminal) revealed that the client was able to feel dull and sharp objects with intact closed eyes. CN VII (facial nerve), the client was able to smile with an intact eyebrow lift. CN VIII (acustic) revealed that the client’s hearing was intact without any difficulties, and CN IX and X (glossopharyngeal and Vagus) assessments revealed an intact gag reflex with no tracheal deviation. CN XI (spinal accessory) assessment showed that the client was intact and had the ability to shrug his shoulders while CN XII (Hypoglossal) assessment showed that everything was intact with an enhanced ability to move the tongue in all directions.
Mental Status Exam
The client generally appeared to be younger than the age that was stated and was dressed in a dark and oversized dress. She was cooperative although showed some resistance especially when his father talked. She had poor eye contact and kept looking all over the room. Her speech was fluent with a slow rate and a low polite tone. She failed to maintain a calm sitting position and kept swinging back and forth with the chair. She has a fluctuating temperament and a fluent effect. She denied auditory and visual hallucinations, suicidal ideations, and delusions. She had a logical and organized thought process and was alert and oriented X3. The client also had no problems with both long terms and short-term memory and had good insight and judgment.
Differential diagnosis
The best differential diagnosis for the client, in this case, is Post-Traumatic Stress Disorder based on the DSM V criteria for diagnosing mental health disorders (American Psychiatric Association, 2013).
Case formulation
The client, in this case, is a 15 year old girl who was referred to the outpatient clinic from the emergency department upon discharge. She had previously sustained a cut injury on her wrist and ankle that was self-inflicted after being verbally and emotionally abused by schoolmates. After reporting the issue to her parents, her mother was supportive and provided her with the support that she needed. However, her father found fault in her and kept on mentioning how she behaved childish on the matter that she ought to let go. As a result, she was frustrated and disappointed. However, both parents realized to some extent how they negatively influenced the client’s behavior and are ready to be part of the family therapy.
Treatment plan
As recommended by Saxe et al., (2017), the client and her family will continue with family therapy once every week.
Part 2: Family Genogram
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Forbes, H., & Watt, E. (2015). Jarvis’s Physical Examination and Health Assessment. Elsevier Health Sciences.
McGrath, J. J., Petersen, L., Agerbo, E., Mors, O., Mortensen, P. B., & Pedersen, C. B. (2014). A comprehensive assessment of parental age and psychiatric disorders. JAMA Psychiatry, 71(3), 301-309.
Silverman, J., Kurtz, S., & Draper, J. (2016). Skills for communicating with patients. CRC Press.
Saxe, G. N., Ellis, B. H., Fogler, J., Hansen, S., & Sorkin, B. (2017). Comprehensive Care for Traumatized Children: An open trial examines treatment using trauma systems therapy. Psychiatric Annals, 35(5), 443-448.