Assessing Client Families Essay Paper

Assignment 1: Practicum – Assessing Client Families
Learning Objectives
Students will:
Assess client families presenting for psychotherapy
Develop genograms for client families presenting for psychotherapy
To prepare:
Select a client family that you have observed or counseled at your practicum site.
Review pages 137–142 of Wheeler (2014) 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.
The Assignment
Part 1: Comprehensive Client Family Assessment

Create a comprehensive client assessment for your selected client family that addresses (without violating HIPAA regulations) the following:

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 and/or trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan
Part 2: Family Genogram

Develop a genogram for the client family you selected. The genogram should extend back at least three generations (parents, grandparents, and great grandparents).  Assessing Client Families Essay Paper

Note: Please make sure the paper includes a title page, introduction (including a purpose statement), summary, and references. Lastly, Please follow uploaded rubric.

Assessing client families

Part 1: Comprehensive client family assessment

Demographic information

Patient’s Name: ‘Peter’ (pseudonym)

Sex: Male

Date of birth: 1979

Age: 39 years

Religion: Muslim

Marital status: Single.

Legal Status: Independent

Preferred Language: English

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Presenting problem

The patient reports that since he was discharged from the military 18 months ago, he has increased his alcohol consumption and drugs use. He reports that he turned to these chemical agents as a strategy for coping with the stressful condition he faced after discharge. The stress was from adapting to life at home without a job while facing significant financial responsibilities. He further adds that while in the military, he was deployed multiple times to the warfront as an infantry soldier and was allowed to spend very little time at home between deployments. He also mentions that for the last eight months, he has been persistently feeling sad and worthless, with a general lack of desire to engage in pleasurable activities (such as sports) that he would previously engage in with friends. He feels hopeless, empty, dejected and melancholic, preferring to spend his time at home either drinking or using drugs rather than engaging in social activities with others. He finds it difficult to express his feelings while exhibit loss of interest and joy in activities he previously considered hobbies. He lacks motivation, is unable to concentrate in an activity, and suffers from insomnia. He mentions that: “I feel that I am not making any progress in life, and am in fact regressing since I am not at work, and am dependent on drugs and alcohol.”

History of present illness

The patient has been feeling hopeless, empty, dejected, sleepless, and melancholic since he was discharged from the army 18 months ago. He has turned to alcohol and drugs as a coping mechanism, with is dependence increasing over time. He is not at work and is stressed.

Past psychiatric history

The patient has no history of mental illness.

Medical history

The patient is not on any medication and has no significant medical issue.

Substance use history

The patient takes significant amounts of alcohol and drugs.

Developmental history

She did not have any developmental delays.

Family psychiatric history

The patient reports that there is no known history of psychiatric ailments in her family.

Psychosocial history

Prior to being discharged from the army, the patient led an active life and consumed moderate amounts of alcohol at social gatherings. After being discharged, he left his friends in the army. While he was discharged and is at home, his friends are in the army and cannot join him for social activities as was the case previously. Also, he has been unable to find work. This situation has stressed him and caused him to turn to alcohol and drugs as a coping mechanism.  Assessing Client Families Essay Paper

History of abuse/trauma

The patient has no history of abuse, although he has spent time in hospital recuperating from wounds he received as a soldier in the battlefield.

Review of systems

General: Has a straight posture.

Skin: Pallid skin.

Head: No history of headaches.

Eyes: Good vision.

Ears: Vertigo.

Nose: No running nose.

Mouth and Throat: No pain or sores.

Neck: No pain or masses.

Respiratory: No hemoptysis, sputum, wheezing, or cough.

Gastrointestinal: No black stools, diarrhea, vomiting or nausea.

Genitourinary: No urination urgency or frequency.

Neurologic: No paralysis.

Musculoskeletal: No joint or muscle pain.

Hematologic: No history of anemia or bleeding disorder.

Emotional: No history of psychiatric problems except for routine counseling as a soldier.

Physical assessment

Vital signs completed: 1:38

B/P: 128/74

Pulse: 68 BPM

RR: 17 BP

Temp: 37^oC

Pulse Ox: 99%

Weight: 90 kg

General appearance: Appears alert.

Skin: No abnormal lesions or moles noted.

Neck: No masses.

Cardiovascular: Regular rhythm and rate, no gallops, rubs or murmurs.

Lungs: No crackles or wheezes.

Mental status exam

Cooperative during the psychiatric examination.

Differential diagnosis

The patient suffers from major depressive disorder (Marchand, 2012). The condition is characterized by persistent feelings of worthlessness and sadness, compounded by a general lack of desire to engage in enjoyable undertakings. In addition, he appears to suffer from alcohol and drugs abuse that is resultant from the stress he experiences because he is unable to find work after being discharged from the military (Sadock, B., Sadock, V. & Ruiz, 2014).

Case formulation

The patient is brought in to address the major depressive disorder with the alcohol and drug abuse considered as resultant from the disorder.

Treatment plan

Treatment with prescription Fluoxetine (Prozac) immediate release oral formulation at 20 mg orally once daily. This is a selective serotonin reuptake inhibitor (SSRI) that is expected to address the patient’s depressed mood (Acton, 2013). In addition, the patient will be subjected to interpersonal therapy that encourages the patient to explore his feelings to address any issues that limit his capacity to socially engage with the people around him (Cautin & Lilienfeld, 2015).

Part 2: Family genogram

References

Acton, A. (2013). Major depressive disorders: new insights for the healthcare professional. Atlanta, GA: Scholarly Editions.

Cautin, R. & Lilienfeld, S. (2015). The encyclopedia of clinical psychology, Volume II Cli-E. Hoboken, NJ: John Wiley & Sons.

Marchand, W. (2012). Depression and bipolar disorder: your guide to recovery. Boulder, CO: Bull Publishing Company.

Sadock, B., Sadock, V. & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry (11^th ed.). Philadelphia, PA: Wolters Kluwer.  Assessing Client Families Essay Paper