Posted: October 6th, 2022

Comprehensive Client Family Assessment

Comprehensive Client Family Assessment
Demographic Info
The shopper is 25-year-old Caucasian feminine who has by no means been married. She lives is a lives in a suburban space within the Midwest. She has one daughter. She employees on the hearth station. She speaks English. The shopper is a graduate in an area college. She attends a Presbyterian native church weekly.
Presenting Downside Historical past or Current Sickness
“I’ve been unhappy and with no urge for food for the final one week. I’m often bubbly and lively. I wish to really feel higher.”
Previous Psychiatric Historical past
The shopper has no important psychiatric historical past. She has been feeling unhappy and no urge for food for the final one month. The situation has not improved regardless of interventions from family and friends members. She remembers experiencing an analogous feeling final yr. She data a historical past of missing curiosity in interacting with different individuals.
Medical Historical past
She has no historical past of hospitalization. The affected person had viral bronchitis and customary chilly throughout childhood. She denies historical past of meningitis, seizure, psychological problems, and falls.
Substance Use Historical past
The affected person has a historical past drug and alcohol abuse. She solely takes alcohol throughout household occasions or with buddies. She has a historical past of marijuana however stopped after rehabilitation. She denies abusing heroine or narcotics. She solely takes great amount of caffeine and nicotine when feeling burdened.
Developmental Historical past
The shopper was born full time period with three.94kg by means of vaginal start. All immunizations are updated. Her menstrual cycle begun usually at 12 years. She dated a boyfriend in faculty, to whom she misplaced her virginity at 19 years. The shopper denies sexual abuse and emotional points. She insists of household points that make her really feel much less priceless.
Family Psychiatric Historical past
Her mom struggling postpartum despair after giving start to her. Her mom didn’t take any treatment however solely went for remedy. The household has no suicide or substance abuse points. The household has no seizure or psychological historical past points.
Psychosocial Historical past
She lives in a middle-class society with low crime price. The shopper is just not prepared for a dedication in any relationship. She is an employed hearth station supervisor. The shopper doesn’t really feel safe about her job. She needs a job that makes her really feel safe and cherished. She has misplaced curiosity in numerous points together with household or buddies occasions. She feels remoted from her buddies. She nonetheless attends church each week.
Historical past of Abuse and/or Trauma
She denies historical past of abuse in household or at work. Her solely traumatic occasion was when her boyfriend determined to depart her. She was crushed by the previous girlfriend and abused in public. She has no historical past of violence. No suicidal concepts however carries a gun in her automotive.
Assessment of Techniques
Eyes – no imaginative and prescient issues
Ears – no listening to issues
Nostril – no working nostril or lack of scent
Throat and mouth – no dental issues or tonsils.
Head and neck – denies headache and ache
Respiratory – no important concern
Cardiovascular – no edema or dyspnea.
Psychiatric – no historical past of psychological sickness.

Bodily Assessment
Ache – the affected person denies any ache.
Peak/weight – ht 5’three and wt 110lbs
BMI – 19.2
Psychological Standing Examination
The affected person has a flat impact. She appears first rate however her sneakers are messy.
Angle and conduct – she cooperates through the interview.
Speech – clear and coherent
Motor exercise – walks sluggishly.
Temper- unhappy.
Notion – denies hallucination
Judgment – understands her actions.
Differential Analysis
Main depressive dysfunction – the psychological situation results in lack of curiosity, suicidal ideation, and unhappiness. In accordance with DSM-5, the situation includes of a 2 week interval of modifications. The reason for the despair is just not identified.
Seasonal despair – it’s a situation that impacts individuals in particular seasons of the yr. It largely impacts girls.
Substance-induced depressive dysfunction – using medication impacts the temper of people. Signs embody inhalation, ingestion, and withdrawal signs.
DSM-V Analysis – Main depressive dysfunction.
Case Formulation
The affected person stories lack of curiosity, unhappiness, and lack of urge for food. She struggles concentrating at work. The situation has affected her private and profession life. She suffers from single episode and average depressive dysfunction.
Remedy Plan
The aim is to cut back the signs utilizing treatment and psychotherapy or a mix of each. The primary treatment is utilizing serotonin reuptake inhibitors reminiscent of fluoxetine 20mg every day. The shopper ought to start psychotherapy as soon as per week. The shopper ought to take a blood assessments to rule out attainable infections.

Half 2: Family Genogram

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