The Assignment
Part 1: Comprehensive Client Family Assessment
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.
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).
Patient
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.
Treatment plan:
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.
Hernandez Family: Episode 6
Hernandez Family: Episode 6 Program Transcript
FEMALE SPEAKER: So last week I showed you how to make a genogram, like this one. Now, the idea behind making a genogram is to help you draw a picture of your family history. And then we use that to discuss the relationships and connections among your relatives. OK? So Juan, why don’t you start off and talk about what you came up with.
JUAN HERNANDEZ: So we’re starting with my family. My father, Hector, he’s still alive. And he married my mother, Freda. And she passed away two years ago. And then there’s their children, myself– I’m the oldest– and then there’s my three sisters, Marie, Senta, and Rose.
FEMALE SPEAKER: Good. And Elena, what about your family?
ELENA HERNANDEZ: Well, here’s my father, Anthony. He met and married my mother, Sofia. They are both still alive. They had five children. Firstborn was my brother Daniel, then my brother Tomas, then my sisters Martina and Camila, and there’s me, the baby.
And then I met Juan, and we started our own family. And we have two beautiful sons that you met, one, Junior, who is eight, and Alberto, who is six.
FEMALE SPEAKER: Good. So for the last several weeks we’ve been talking a lot about how you discipline your sons at home. And both of you mentioned how your parents used to punish you when you were growing up. Juan, why don’t you talk about that and point to anybody on the genogram as you mention them?
JUAN HERNANDEZ: Sure. So my dad, when he was mad at me he would send me to get books from the encyclopedia. And he’d make me hold them out, straight out like this, until he told me to stop. It caused so much pain in my arms, I mean, my arms felt like they would break off.
And my mom, she did basically the same thing. Except when she was really mad, when would make me get more books than my dad. I hated those books so much. I never went near them on my own. To me, they only meant one thing, misery. And now, I guess I inherited that from them.
FEMALE SPEAKER: Elena, how about you?
ELENA HERNANDEZ: Yes, misery. That’s what it was like for me, too.
© 2016 Laureate Education, Inc. 1
Hernandez Family: Episode 6
Hernandez Family: Episode 6 Additional Content Attribution
MUSIC: Music by Clean Cuts
Original Art and Photography Provided By: Brian Kline and Nico Danks
© 2016 Laureate Education, Inc. 2
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