Comprehensive Client Family Assessment

Part 1: Comprehensive client family assessment

Demographic information

Patient Name: ‘Mary’ (pseudonym)

Sex: Male

Date of birth: 1953

Age: 65 years

Religion: Christian

Marital status: Divorced.

Legal Status: Independent

Preferred Language: English

Presenting problem

The patient reports that she is a divorced retiree who complains that she has developed a general lack of interest in activities that she initially found pleasurable. In fact, she is moody and finds little joy in life, but is unclear as to the cause of her moodiness. Still, she indicates that her mood improves from engaging in some activities. Besides that, she has difficulty falling asleep at night and wakes up at around 4 a.m. after which she cannot go back to sleep even though the morning finds her feeling very tired. In addition, she has gained weight and feels tired most of the time even going on to have anxiety that her family abandoned her in the home. She has gained weight but believes this resultant of overeating and not engaging in exercise activities. Se reports that: “I have been thinking of committing suicide to relieve the burden that I have placed on my family since they dumped me in the assisted living community, rarely visit me but pay for my needs and continued stay in the community Comprehensive Client Family Assessment.”

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History of present illness

The patient has been feeling down since she was first admitted into the assisted living community two years ago. Her feelings have only worsened over time since her children nave failed to visit her except for when she was first admitted into the facility.

Past psychiatric history

The patient has a history of insomnia that was diagnosed four years ago and is under medical management.

Medical history

The patient is currently taking medication to manage her insomnia. In addition, she has been taking medication to manage her arthritis for the last two years.

Substance use history

The patient stopped taking alcohol ten years ago and has not used any other substances except for prescribed medication. .

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

The patient has previously been jovial and spent most of her time with her grandchildren, especially after her retirement. Things changed when she became increasingly dependent even as her arthritis worsened. That is because she was transferred into the assisted living community where contact with her grandchildren has been minimized. This has made her feel abandoned Comprehensive Client Family Assessment.

History of abuse/trauma

The patient reports that her husband is a veteran and he became increasingly violent during the later years of their marriage thus resulting in her suing for divorce on grounds of cruelty. It was only after the divorce that her ex-husband sought psychiatry treatment and was diagnosed with PTSD.

Review of systems

General: Appears weak and stoops when walking.

Skin: Pallid skin.

Head: History of headaches following domestic abuse.

Eyes: Short-sighted (resultant from age) causing her to use bifocals to correct her vision.

Ears: Vertigo.

Nose: No running nose.

Mouth and Throat: No pain or sores.

Neck: Slight pain in the joints but no 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: Reported joint and muscle pain from arthritis.

Hematologic: History of transfusion. No history of anemia or bleeding disorder.

Emotional: No history of psychiatric problems except for routine counseling following domestic abuse.

Physical assessment

Vital signs completed: 1:38

B/P: 128/74

Pulse: 68 BPM

RR: 17 BP

Temp: 37oC

Pulse Ox: 99%

Weight: 67 kg

General appearance: Appears alert.

Skin: No abnormal lesions or moles noted.

Neck: No masses Comprehensive Client Family Assessment.

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

Lungs: No crackles or wheezes.

Mental status exam

The patient was cooperative during the psychiatric examination.

Differential diagnosis

The patient suffers from atypical depression (Wheeler, 2014). Given the presented symptoms, the patient suffers from atypical depression based on characterization presented in DSM-5. The diagnosis notes that she has increased appetite that caused her to gain weight (Cautin & Lilienfeld, 2015). In addition, she suffers from heavy limb sensation causing her to feel tired most of the time. Also, the patient suffers from interpersonal rejection sensitivity that explains her suicide ideation (Acton, 2013).

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Case formulation

The patient is brought in to address the atypical depression.

Treatment plan

Two strategies would be applied to manage the patient’s atypical depression. The first strategy entails using prescribing Celexa medication. This is an antidepressant that selectively inhibits serotonin reuptake. The second strategy entails subjecting the patient to psychotherapy that uses dialogue to identify ways for relieving her symptoms (Smith, 2012).

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.

Smith, G. (2012). Psychological interventions in mental health nursing. Berkshire: Open University Press.

Wheeler, K. (Eds.). (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.

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