Assessing client's progress

Part 1: Comprehensive client assessment

Demographic Information

LS is 23 year old white male who lives with his parents. His parent moved to the united states from Russia to get a better live for their only son LS. LS had been depressed since the move and feels like he is unable to cope in the new environment . LS struggle with learning English and not doing well at school as a result.

Presenting problem

Depression and suicide

History of present illness

LS is stress out with school and has dropped out several times. His parent have found him on several occasions cutting self and trying to overdose on his pills. He says he is depressed 10/10. He was medically clear after overdosing on his medication 4 weeks ago and now presented for treatment and monitoring. Hopelessness suicidal ideations, and loneliness can contributes to depression, which can result in attempts of suicide Hamet & Tremblay (2005).

Past Psychiatric History

LS denies any past psychiatric History, but his father has been treated for depression before.

Medical History

No medical History, denies any pain.

Substance Use

Ls admits the use of marijuana but deines alcohol, or other drug use.

Developmental History

LS is an immigrant from Russia who is unable to cope in his new environment.

Family Psychiatric history

Father was diagnosed and treated for depression 12 years ego. His grand father also suffered from depression.

Psychosocial History: An only child, no siblings, mostly alone, no close friends or relative apart from parents.

History of abuse /trauma

LS feels he was traumatized by coming to another country unable to understand the lagage and his parent barely making it. LS parent are uneducated and works as farmers. LS feel worried about his parent struggling to make a living.

Review of Systems

General: Denies chiles or malaise, no weakness or fatigue. Appears flat, A/O x 4, weight 120, Height 5’4

Skin, Hair, Nails- Intact

HEENT: Denies head ache, dizziness, syncope. No tinnitus, no changes in vision.

Cardiovascular: No pain on palpation, no heart murmurs on auscultation, pulses palpable.

GI: bowel sound present on all four quadrants, no distention, contour symmetrical.

GU: continent with regular urinary pattern

Musculoskeletal : Normal skeletal structure, no deformities or abnormalities.

Hematology : Denies Anemia, no bleeding or bruising .

Edocrine: No issues, denies increased thirst or urination.

Mental Status Exam

LS presents calm and cooperative during this visit. He appears well groomed with poor hygiene, poor eye contact, flat affect. Speech is clear and presured though minimally engauging probably due to him thinking his English is not very good. Able to state reason for visit and and wants to get help. He denies any thought of self harm at this time, not hearing voices and no visual hallucination. LS is distracted but redirectable. He has poor appetite, parents encouraged to bring him food. Lacks motivation to participate in group activities. Endorses rate of depression as 10/10, suicide risk as very low.

Differential Dignoses

Major depressive disorder

Post traumatic stress disorder

Depression with psychotic features.

Case formulation

Family psychiatric history reveals that genetic factors increase suicidal ideation. It is well known that client LS had a family who was involved with suicidal history Block (2000). Also, family problems can cause depressions due to the financial difficulties, which bring in a lot of stress leading to suicidal ideation.

According to Nezu, McClure & Zwick (2002), mental disturbances can led to depression. LS was unable to communicate with other individuals around him; thus, he could not share the problems he was undergoing, leading to his suicidal attempts.

Treatment Plan

LS will verbalize feelings to staff when feeling overwhelmed by discharge ~ to help LS develop rapore and coping skills ~ LS will be monitored 1:1 by staff for safety.

LS will attend daily groups till discharge ~ to halp LS develop social skills ~ staff will encourage LS to attend group activities every day.

LS will take medications as ordered by discharge ~ to improve mood and reduce thoughts of self harm ~ staff will administer medications to LS as needed.

Part 2: family genogram.

Reference.

Block, S. D. (2000). Assessing and managing depression in the terminally ill patient. Annals of internal medicine, 132(3), 209-218.

Fawcett, J., Clark, D. C., & Busch, K. A. (1993). Assessing and treating the patient at risk for suicide. Psychiatric Annals, 23(5), 244-255.

Hamet, P., & Tremblay, J. (2005). Genetics and genomics of depression. Metabolism, 54(5), 10-15.

Nezu, A. M., Nezu, C. M., McClure, K. S., & Zwick, M. L. (2002). Assessment of depression. Handbook of depression, 2.