Wk3 Practical Assgn
See attached. The second attachment wk 3 OLD… will direct you on how to present this assign. No Plagiarism please. Thanks
CB: Patient with increase anxiety, depression and sexual abuse trauma
The patient is 21-year-old female college student with present history of anxiety, depression and past hx of sexual abuse. She did experience trauma in the context of sexual abuse during first year of college. Patient states she trying to get better by focusing on finishing college. I have bought new laptop, organizer to plan all my assignments and also applied for job at FedEx. Patient states her depression is better but still feels very anxious. Patient cannot get over how Mom broke the trust she had on her by revealing her sexual assault trauma to family members and relatives. Patient states she is presently not in good relationship with mom and her anxiety gets worse whenever she meets mom. Mom has hx of alcohol abuse and would do things for her children just for personal gains. Patient states mom revealed to her kid sister as well as her cousin about her sexual assault. Patient states she presently suffers from this lack of trust and as a result it affects her perception of Mom good dead and her emotions and also increases her level of anxiety to the extent she cannot stand before a stranger. On one occasion, mom and her cousin visited her in school (Washington DC) on her 20th birthday, and mom felt her presence was not recognized as all attention was more on her cousin. Mom got upset and called security to escort this patient out of the hotel room. Patient states she is currently at home with mom and siblings due to the closure of school relating to covid-19 pandemic. Patient states mom continue to refer to her sexual abuse incident which increases her level of anxiety and depression. Mom broke my trust by revealing this assault to my little sister and my cousin which I feel it is intentional just to make me sad.
During this session, patient appears to be calm initially then later became tearful as she continues to express how heartbroken she has been knowing that mom is internationally revealing this assault invent to hurt her and makes her anxious.
Patients continue to hold this grudge against mom, believes mom does not meal well for her and she continue to have difficulty developing understanding with mom.
Students will:
Assess clients presenting for psychotherapy
Develop genograms for clients presenting for psychotherapy
To prepare:
Select a client whom you have observed or counseled at your practicum site.
Review pages 137142 of the Wheeler text and theHernandez Family Genogramvideo in this weeks 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
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). Practicum Assignment: I. Case Study: Comprehensive Family Assessment
P
V
Psychotherapy with Individuals
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Demographic Information:
Isabella A. is a 15-year-old, Hispanic female
Presenting Problem
IA was having extreme anxiety and conflicts with mother and mothers boyfriend. According to mother, IA believes mother does not love her and is always comparing her to other kids her age. IA and mothers boyfriend do not get along, frequent fights, quarrelling and anger outburst. IA believes mothers boyfriend is always criticizing her. IA has anxiety that affects her and feels that she is not loved. IA decided to overdose on medications. IA also started street drugs to make herself feel better just like mother when mother was into drugs. IA has a thirteen-year-old sister and an eight-year-old half-brother. IA is constantly fighting with her sister. IA admits anxiety all the time and is not happy living in their home with family members. IAs father is not in the picture. According to IA, father drinks a lot and mother was into drugs, IAs father has divorced mother and has remarried to another woman with two children. Mother has moved on with her boyfriend and both have one child together.
History or present illness
Frequent mood swing, anger outburst, anxiety, fight, and drug use reported, Xanax, and LCD. Previous attempt to commit suicide by overdosing on medication.
Presenting signs and symptoms:
Helplessness, hopelessness, sleeplessness, poor concentration, and physiological symptoms of anxiety.
Precipitating circumstances:
Housing problems, poor coping skills and feels unloved and unsupported by family
Past psychiatric history
Mother reports that IA was diagnosed with Major Depressive Disorder, recurrent episodes at age 10.
Medical history
IA does not have any medical condition, but her dad has High blood pressure.
Substance use history
IA reports to have use LCD, Xanax, and but denies smoking marijuana.
Alcohol History:
IA denies use of alcohol.
No Known Allergies
Current Medications:
Vistaril capsule 50 mg, 1 capsule orally, TID PRN
Trazodone tablet 50 mg, 1 tab orally, at nighttime.
Developmental history
No developmental delays reported by the parent
Family psychiatric history
Maternal Grandmother has bipolar
Psychosocial history
IA is social, socialized with children of her age on the street, skating and playing basketball together. Plays football in the school as well
History of abuse/trauma
No history of sexual or physical abuse. IA lives with her mother and the dad is not in the picture, IA said that her dad has remarried and has 2 other kids with his current wife.
Review of system
General: No fever, no weakness or fatigue, night sweats or any malaise
Head: No Migraine headaches reported, no dizziness, syncope or vertigo reported
ENT: No visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, sore throat, or any speech difficulty.
Neck: Denies any neck swelling, pain, goiter, or masses, nodes
Cardiopulmonary: No cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea edema syncope, hypertension, or any heart murmur
GI: No changes to eating habit, denies any heartburn, constipation, nausea/vomiting, abdominal pain, change in bowel habit.
GU: No dysuria, frequency, nocturnal, hematuria, burning, discharges, urgency incontinence or polyuria
MS: Gait is steady, no backache, joint pain, or stiffness reported.
Heme/Skin: No bleeding, bruising or anemia. Denies changes, pruritis, rash, or changes in hair.
Neuro: No indication of seizures, paralysis, any muscle weakness paresthesia, or sensation changes
Psych: Major Depressive Disorder, Anger issue reported, with mood swing and use of LCD, and or Xanax. Denies SI, HI or AVH, rated depression at 4 out of 10 and frequent anxiety disorder currently.
Physical assessment:
Vital Signs
Weight is 128lbs
Height is 5 5
BP: 117/62
RR: 18
Temp: 97.7
Pulse: 82
Appearance: Patient appear healthy, non-obese, and with normal age appearance without any observed distress. Well-groomed and dress appropriately.
HENT:
Head: Normocephalic.
Right Ear: External ear normal
Left Ear: External ear normal
Nose: Nose normal.
Eyes: EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.
Neck: Normal range of motion.
Cardiovascular: Normal rate.
Pulmonary/Chest: Effort normal.
Neurological: She is alert. Coordination normal
Skin: Skin is warm and dry. No rash noted. She is not diaphoretic. No erythema. No pallor.
Psychiatric: Her mood appears anxious. Her affect is labile (tearful, anxious, and agitated). Her speech is tangential. She is not aggressive and hyperactive. She expresses impulsivity. She exhibits a depressed mood.
FAMILY PSYCHIATRIC AND MEDICAL HISTORY:
Significant Family History:
IAs father is an alcoholic and mother had history of drug abuse. Mother and father are no longer married., Paternal grandmother: HTN, chronic smoker, paternal grandfather: colon cancer, Maternal grandmother: depression, maternal grandfather: hyperlipidemia, HTN, substance abuse alcohol
Mental Status:
Appearance: Clean, neat and dresses appropriately.
Appears stated age and healthy: Yes.
Eye contact: Good
Level of activity: relaxed.
Gait: steady.
General Behavior: active. Cooperative
Speech rate: normal.
Volume: normal.
Articulation: good.
Mood and Affect: appropriate
Affect: Normal.
Mood: depressed, nervous/anxious.
Severity: moderate.
Concentration: Normal.
Orientation: person place, time, and situation.
Memory: intact recall.
Intellectual Faculties: borderline.
Abstract ability: fair.
Similarities and differences: fair.
Thought Processes: logical. Goal directed.
Structure: Normal.
Associations: tangential and flight of ideas.
Thought Content: Normal
Hallucinations: none suspected.
Severity: hallucinations none suspected.
Delusions: none suspected.
Aggression risk: no aggression risk demonstrated.
Differential Diagnosis:
Generalized Anxiety Disorder (GAD).
Case Formulation:
IA parents are divorced. The dad is no longer actively featuring in her life since age 10. The dad has made several attempts to come back into the kids life with no positive outcomes since dad has other 2 kids with a different woman and has difficulty to share enough attention. IA understands that dad is trying. Mother drops IA off for individual therapy session. Mother is 33-years-old Hispanic-American woman. Mother has history of Major depressive Disorder, drug abuse, and alcohol use but has sobered up. IAs dad has alcohol use disorder and barely present in her life and not here today.
Treatment Plan/Goals
The patient will participate in partial hospitalization program, (PHP). Patient will come in 5 times in a week for therapy session with mother. Family group will be available 3 times a week out of the 5 days. The goal is to teach patient on how to cope and redirect patient during anxiety, depression and or anger episodes. There is goal and process group, psych education/skills and medication education twice a week.
Estimated completion: 30 days
Objective #1
IA and mother will be able to have a healthy coping skill with IAs episodes of anxiety, depression, and anger outburst. IA will understand venting, distraction techniques and how to manage her frustration. Mother will learn to understand the importance of recognizing age-appropriate behavior of her daughter.
Objective #2
IA will be able to have a positive coping skill to use in anxiety, depression, and anger situations, refrain from overdosing and or use of street drugs. Also, she will be compliant with her medications as prescribed by the provider and understand to be drug free.
Post Completion
Patient will be discharged to follow up with her primary provider and counselor to be stabilized.
References:
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.).
IA Genogram.
Great Grand mother
Great Grand Mother
Great Grand Father
Great Grand Father
Uncle
Aunt
Grand Mother
Grand Father
Uncle
Cousin
G/Mother
Grand father
Brother
Sister in law
Aunt
Uncle
Step Brother
Step Sister
Half Brother
Sister
Step Mom
Father Alcohol
Boy friend
Mother Drugs
Brother in law
IA 15
