COMPREHENSIVE FAMILY ASSESSMENT

COMPREHENSIVE FAMILY ASSESSMENT 2

COMPREHENSIVE FAMILY ASSESSMENT 6

March 17, 2018

Running head: COMPREHENSIVE FAMILY ASSESSMENT 1

COMPREHENSIVE FAMILY ASSESSMENT

PART 1. CLIENT COMPREHENSIVE FAMILY ASSESSMENT:

A client with bipolar type 1

Demographic Information: Aunt Kay is a 40 year old American female accompanied to the health center by her brother Blix. She is an employee in the public service but lives in her father’s extended family that is in the same compound with her siblings.

Presenting Problem: Medical examination on Aunty Kay was important as it helped find out her medical history as a psychiatrist, setting mental health evaluation tests will help in getting specific information about the client’s condition. This is the key to avoid mistakes which may occur as a result of mistakenly identifying depression as bipolar or bipolar as depression. The client stated that her family-based psychiatrist had not previously identified her with bipolar disorders, but the reports from her medical history presumed that she had concurrently experienced depression which was severe. Additionally, it was also reported that her grandfather had bipolar disorder, therefore, there was a base for developing and diagnosing her with the bipolar disorder since it is genetic.

Historical Background: Aunty Kay came from a family which had reported cases of bipolar disorder and since the condition is genetic it had been passed through generations. She showed the following signs which helped in diagnosing bipolar disorder; she reported that she had depressive episodes over a period of 2 weeks, fatigue, suicidal thoughts, depressed mood, and insomnia (Ketter, 2010). Bipolar disorder is identifiable from periods of deep and profound depression that alternates within seasonal periods.

History or present illness: From the family health records, it was stated that she had recently recovered from Schizophrenia which may be a sign that her state had outgrown the low depression into the manic state of mood swing which is a clear indicator that she was having a bipolar disorder. She was also reported to have been in a depressed state, she no longer likes being with the other persons, and she has lost her self-belief and confidence in carrying out her day to day activities her contribution from all ends has gradually deteriorated.

Physical Assessment: An assessment of her physical state showed that she had become selfless, felt restless, was easily distracted, sometimes maintained long periods of feeling high, experienced memory problems, could not concentrate to one thing, showed severe fatigue, and did not like to stay with the rest of family (Ketter, 2010). Therefore, all was clear that condition she suffered from was bipolar disorder.

Past psychiatric history: It was reported that she had recently recovered from Schizophrenia.

Medical History: Hypokalemia, and Diabetes

Past Surgical history: History of rotator cuff repair due to injury, knee replacement and Appendicitis.

Substance use history: Patient admits that she is an occasional alcoholic.

Development history: She reported normal and good development.

Family Psychiatric history: As stated she had reported cases of depression and bipolar

Psychosocial history: She is a graduate working as a public servant in New York, over recent times she has shown some signs of separating herself from the rest of colleagues, she suddenly gets distracted and has periods during which she is unhappy. Auntie Kay has a family and while at home she shows sadness which sometimes is not healthy for her family.

History of abuse/trauma: Patient stated that she was abused by her ex-husband

Mental Status Exam:

Behavior/Motor: She showed no sign of abnormal movement, and none was observed, maintains eye contact with appropriate expressions; comfortable and cooperative;

Orientation: She is alert and oriented x4

Speech: Her speech was normal in all dimensions.

Mood/Affect: She reported severe mood swings with periods of flat affect

Attention/Concentration: She was attentive but easily got distracted and withdrew.

Immediate memory: Normal as she could remember her recent 3-4 encounters.

Recent memory: Normal as she could account on her recent past days activities.

Long-term memory: Normal as she clearly remembered her childhood main encounters and achievements.

Physical Exam/Assessment

Vital signs: B/P 150/72, left arm, sitting, regular cuff; P 70 and regular; T 98.3 orally; RR 18; non-labored; O2 -100 Wt: 180 lbs; Ht: 5’9; BMI 22.

Pain: Pt denies

HEENT: PERRLA, EOMI, or nasopharynx is clear and well aligned, no drainage noted

Neck: Supple, full range of motion. No thyromegaly. No carotid bruits. No masses palpated. No tracheal deviation noted.

Chest/Lungs: Lungs sounds clear bilateral equal with no shortness of breath or abnormal sounds noted.

Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilateral pedals and +2 radial

ABD: Bowel sound equal and present on all four quadrants

Genital/Rectal: Deferred

Musculoskeletal: No arthralgia/myalgia, no arthritis, gout or limitation in his range of motion by report. History of rotator cuff repair due to injury.

Neuro: CN II – XII grossly intact, DTR’s intact

Skin/Lymph Nodes: Skin is intact, no lesion, rash, edema or skin break down noted

General: Overall appearance well groomed, dressed appropriately to the weather.

Respiratory: Denies shortness of breath or any difficulty breathing.

Integument: No skin breakdown, lesion, rash ort itching noted.

Endocrine: Hx of diabetes

Allergic/Immunologic: NKDA noted

GU: Denies UTIs and STDs. Pt is not sexually active

CV: Denies chest pain/discomfort, palpitation and edema

GI: Denies N/V, abdominal pain and constipation

MS: ROM noted within normal with no pain noted.

Differential diagnosis: Bipolar/Mood Disorder

Case formulation: Flat affects, depression, mood swing, Aunty Kay is a well-respected public servant, but life took a turn around after the loss of her boyfriend of 5 years. She became withdrawn, depressed; she also suffered from mental stress because she was physical and mentally abused by her ex-husband. Pt refuses to participate in the family activities little or no peer interaction. Persistent empty or “blue” feeling, lack of interest or pleasure in usual activities Sleep changes, lack of motivation and neglect of routine tasks such as personal grooming.Pt denies visual or auditory hallucination but stated that sometimes she has flash backs from the abuse by her ex-husband.

Treatment Plan: Bipolar disorder is a lifelong condition that if not carefully treated can cause extensive damages to an individual’s life as a result of the ups and downs that one experiences when getting through the depression phase and to the manic episode. Early and professional treatment is advisable as it will help one to stand against odds of all problems associated with the condition (Ketter, 2010).

Pt will seek the help of a therapist and psychiatrist, plan to attend counseling sessions and support group a forum for counseling and sharing experiences among people with a similar condition or goal, such as depression or bipolar. The use of CBT can help on modifying negative thoughts and alleviate some psychological distress. Psychoeducation, family therapy or session and psychotherapy treatment of mental or behavioral disorders through talk therapy and also the treatment plan would be the administration of psychotherapy medications whose success will be monitored by the outcome and compliance.

Medications:

Lithium 150mg bid,(monitor the lithium level to avoid toxicity)

Carbamazepine (Tegretol)- 200mg bid

Lamotrigine (Lamictal)-200mg daily

Valproate (Depakote, Epilim) 500mg bid

Abilify-5mg daily

PART 2. FAMILY GENOGRAM

Great Grandmother

Great Grandfather

(92 Deceased (86 Deceased

Bipolar disorder) Schizophrenia)

Martha

Mr. Bill

Dan Caxton

Mrs. Bill

(70 Deceased (60 Deceased (65 Deceased (55 Deceased

Hypothyroidism) Depression) Unknown) Psychosis)

Mom Dee

Uncle Martin

Uncle Blix

Aunt Ann

Dad Job

Aunt Kay

(30 (46 Lung (40 Bipolar (44 Leukemia) (39 ADHD) (61 HTN)

Depression) Cancer) Disorder)

Mary

Gabriel

Gloria

Rose

James

(22 (26 Unknown) (30 (28 Obesity) (38 Arthritis)

HTN) Diabetes)

Janet

Shadrack

(5 Type 2 diabetes) (9 Liver disease)

KEY:

Male

Female

Married

Child

References

Ketter, T. (2010). Handbook of diagnosis and treatment of bipolar disorders. Washington, DC: American Psychiatric Pub.

NIMH: Bipolar Disorder. (2018). Nimh.nih.gov. Retrieved 14 March 2018, from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

World Health Organization (2018). Psychosis and bipolar disorders. World Health Organization. Retrieved 14 March 2018, from http://www.who.int/mental_health/mhgap/evidence/psychosis/en/

This is friends sample but remember her assessment is different

Assignment 2: Practicum – Assessing Client Progress

According to Cameron and Turtle-Song (2002), SOAP format helps in producing a clear and concise note which involves documenting of the client’s sequence of care starting from the subjective, objective, assessment and then to the plan. The format does not only helps in the documentation, but it also helps the counselor in representing the client’s concerns in a historical framework. Progress notes are the ones that establish the progress of the treatment of the client that include the diagnosis, assessment, as well as the treatment protocols. On the other side, privileged notes are the ones that are produced for usage by the patient. This helps the practitioners and other professionals understand the concerns and the needs of the client be

Part One: Progress Note

This is a case of a 14 year- old girl that was seen in week 3 with diagnosis of Eating disorder, Anorexia Restricting Type. The patient was over exercising, restricting meal and fluids as well as obsessed with body image. This client had a fear of weight gain therefore she tend to restrict and over exercise. Patient had a heart rate of 46 bpm. Patient was in patient for refeeding for one week and was placed Zoloft 75mg and daily and Zyprexa 10mg daily. Patient was recommended to work with dietitian and work on meal plan.

Cognitive behavioral therapy (CBT) was introduced during this time. CBT has been proven to help patients with the completion of other homework (e.g., food diaries), and addressing any therapy-interfering behaviors (such as non-completion); weekly weighing; and preliminary dietary change (Waller & Stringer, 2012). According to patient and mom, patient is following

her meal plans and following up with her dietitian. Patient reported she struggle with meals sometimes, still feel guilty after meal. Patient still reporting urges to exercise but has not exercised. There is an improvement with patient’s weight as patient has gained 5 pounds in 4 weeks. She is back to school with good grade. She reports good sleep with at least 7 hours of sleep per night. Although she still has some anxiety especially during meals, she is using her coping skills. Heart rate is within normal limit. Patient is eating meals with family and has family support. She is concentrating better. During the session, Client was in a better mood. She contracted for her commitment to gain more weight, follow her meal plans. She stated she does not want to be back to where she was a month ago. She is aware of the consequences of her eating disorder and contract to seeking help from her family and talking to her dietitian whenever she feels overwhelmed with her meal plan which she thinks is too much. This patient has achieved a positive success as well as being compliant with her treatment team and assignments. Patient is in a better mood, calm and more engaging at this time. According her mom, “She is being her old self again”. She uses distraction as coping skills whenever the Eating Disorder voice tells her she is fat. Patient will continue to attend psychotherapy session, work with her dietitian and see her medical and Psychiatric doctor as needed. She will continue to be monitored close as patient is still at risk of relapsing. Her parents were also made aware to monitor her meal intake and report any changes.

Part 2: Privileged Note

During the session, patient reported that she has a crush on a boy in her class (name withheld for privacy) but not sure if the boy really likes her. She has not told anyone about her crush. She also stated that there is a boy that is asking her out but she does not like him like that. She would like to date a tall, handsome guy who is smart. She stated she would talk to her mom about dating and see what her mom says. I will not include this in her chart as I view this as her privacy violation. The patient also requested that this information remain confidential. Although medical records are designed to be used within healthcare settings, health information may be legitimately acquired and utilized by other organizations, since the value of such information is important and increasingly used in decision-making ( Kuo & Alexander, 2014). I have observed that my preceptor does not use privileged note and when I asked her she stated that she believes the idea that all information coming from the patient should be respected as it can affect the current treatment plan/goal.

References:

Waller, G., Evans, J., & Stringer, H. (2012). The therapeutic alliance in the early part of

cognitive‐behavioral therapy for the eating disorders. International Journal Of Eating

Disorders, 45(1), 63-69. doi:10.1002/eat.20914

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format.

Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)

Kuo, K., Ma, C., & Alexander, J. W. (2014). How do patients respond to violation of their

information privacy?. Health Information Management Journal, 43(2), 23-33. The instructions

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):

· Treatment modality used and efficacy of approach

· Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)

· Modification(s) of the treatment plan that were made based on progress/lack of progress

· Clinical impressions regarding diagnosis and/or symptoms

· Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)

· Safety issues

· Clinical emergencies/actions taken

· Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)

· Treatment compliance/lack of compliance

· Clinical consultations

· Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)

· Therapist’s recommendations, including whether the client agreed to the recommendations

· Referrals made/reasons for making referrals

· Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)

· Issues related to consent and/or informed consent for treatment

· Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported

· Information reflecting the therapist’s exercise of clinical judgment

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment.

· The privileged note should include items that you would not typically include in a note as part of the clinical record.

· Explain why the items you included in the privileged note would not be included in the client’s progress note.

· Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.