Comprehensive Client Family Assessment Essay Paper
Comprehensive Client Family Assessment Essay Paper
Assessing client families
Part 1: Comprehensive client family assessment
Demographic information
Patient’s Name: Mary.
Sex: Female
Date of birth: 1994
Age: 25 years
Religion: Christian Mormon
Ethnicity: Caucasian
Marital status: Married for 2 years
Children: None
Work Status: Office assistant
Preferred Language: English
Presenting problem
Mary is a 25 year old patient who is married to a 29 year old man. She attends family therapy with her husband. She has been married for the last two years. She does not have any children. She works in a highly stressful environment as an office assistant and has the added responsibility of attending school and taking care of her home. She has been referred for psychological assessment by her physician since she has been complaining of trouble sleeping, fatigue, stress, feeling on edge and constant worry. Her physician is concerned that she could be suffering from attention deficit hyperactive disorder (ADHD) and anxiety.
History or present illness
Mary was diagnosed with ADHD as a child and has been taking medication to manage the condition. However, her ADHD symptoms have worsened since she began juggling work, school and family causing her to always be worried about how little or how much she can get done. Comprehensive Client Family Assessment Essay Paper Her husband wants them to have a child but she is worried that she will be unable to handle having a child now since her current responsibilities are overwhelming.
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Past psychiatric history
She was diagnosed with ADHD as a child and has been taking prescription medication to manage the ADHD.
Medical history
She had minor surgery one year ago to correct a reproductive problem, and took pain medication for three weeks following the surgery.
Substance use history
She occasionally drinks in social occasions such as family gatherings. She drinks approximately two glasses of wine every week.
Developmental history
She does not have any known developmental issues.
Family psychiatric history
One of her brothers and a nephew were diagnosed with ADHD. Some of her paternal relatives have been diagnosed with ADHD.
Psychosocial history
She has a good relationship with her family and husband. However, she is concerned that the issue of having a child could cause problems since her husband is insistent on having a child and does not seem concerned about her worries. She is already overwhelmed with her family, work and school responsibilities, and is concerned that adding a child would drive her over the edge. She fears that the pressure to have a child will strain her relationship with her husband.
History of abuse/trauma
No history of abuse or trauma.
Review of systems
General: Has a straight posture.
Skin: Pallid skin tone.
Head: No history of headaches.
Eyes: No problems with vision.
Ears: No vertigo.
Nose: No running nose.
Mouth and Throat: No pain or sores.
Neck: No pain or masses.
Respiratory: No hemoptysis, sputum, wheezing, or cough.
Gatrointenstinal: 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.
Physical assessment
B/P: 136/86
Pulse: 86 BPM
Temp: 37oC
Pulse Ox: 96%
Weight: 72 kg
General appearance: Alert appearance.
Skin: No abnormal lesions or moles.
Neck: No masses.
Cardiovascular: Regular rhythm and rate with no murmurs.
Lungs: No crackles or wheezes.
Mental status exam
Mary has an appropriate general appearance, dressing, affect, thought content, and interview behavior. She has good insight, judgment, attention, and concentration. She has normal speech. She has X3 orientation: is oriented to person, place and time.
Differential diagnosis
Mary is diagnosed as suffering from ADHD and anxiety. She has trouble sleeping, fatigue, stress, feels on edge and is constantly worrying about the many different things in her life. The differential diagnosis is that she could be suffering from personality or depressive disorders since these conditions have similar symptoms to what she is presenting (American Psychiatric Association, 2013; Sperry, 2016).
Case formulation
Mary attends the psychiatric assessment for a diagnosis and treatment plan.
Treatment plan
The treatment plan is for ADHD and anxiety. The treatment will begin with changing her ADHD prescription medication since she is currently taking stimulant medication and this could be causing the anxiety symptoms. Changing to non-stimulant ADHD prescription medication could alleviate the symptoms. In addition, she will be subjected to cognitive behavioral therapy. Besides that, a lifestyle change will be recommended to include better nutrition, scheduling her tasks, and regular exercises (Wheeler, 2014).
Part 2: Family genogram
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Sperry, L. (2016). Handbook of diagnosis and treatment of DSM-5 personality disorders: assessment, case conceptualization, and treatment (3rd ed.). New York, NY: Routledge.
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: a how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company. Comprehensive Client Family Assessment Essay Paper
