- Select a client whom you have observed or counseled at your practicum site.
- Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.
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).
D.H, 26-year-old male Hispanic, was admitted from home from the ED for inpatient psychiatric evaluation and treatment. Allergies to latex, shrimps. He has a history for depression, PTSD, paranoia, anxiety and pseudo-seizures.
Chief complain: Pt has neglected his ADLS and hygiene, not slept and eaten in the past few days before his admission. Pt expressed he has no motivation to live, admits suicidal ideation with no plan, denies homicidal ideation, auditory and visual hallucinations. He stated, “the recent anxiety and depression is from working from home due to COVID, I usually work at the warehouse as a call center representative.” The pt lives with spouse and after he signed the release of information form, pt’s spouse was unavailable when called.
The individual counselling therapy, bio/psychosocial was completed as pt was cooperative, redirectable despite having racing thoughts. He admitted to sexual abuse at 5 years old by the maid but stated he didn’t want to talk about it. The pt was easily distracted, showed signs of depression. He has had 1 prior hospitalizations for mental problems but stated “I was anxious and wanted to calm down at that time.” Pt admits to alcohol use, but no usage lately, also admits to marijuana use 6 months ago.
Dx: Risk for suicide, danger to self, depression, Unspecified Bipolar disorder and related disorder, Major depressive disorder w/o psychosis features, unspecified trauma disorder, unspecified anxiety disorder.
Psychosocial and contextual factors- trauma, marital stress, substance use
Meds: Sertraline 100mg PO qAM, Zyprexa 5mg QAM PO, Xanax 0.25mg PO q6h PRN for anxiety.
Problems: Suicide ideation w/o plan Goals: no SI. Modalities: medication and therapy Problems: Anxiety Goals: decrease anxiety. Modalities: medication and therapy
Problems: Insomnia Goals: Improve sleep Modalities: medication and therapy
Medication Plan: Initiate Seroquel 50mg at HS for mania and Prazosin 1mg at HS for trauma.
Activity therapy: Engage pt in group focused therapy, improve coping skills and managing moods.