Assessing Client Family Progress

Student Name: Semiloore Akerele

E-mail Address: [email protected]

Practicum Placement Agency's Name: Lincolnwood medical center

Preceptor’s Name: Dr Syed Rahim

Preceptor’s Telephone: 8472874505

Preceptor’s E-mail Address:[email protected]

Comprehensive Client Family Assessment

Semiloore Akerele

Walden university : PRAC- 6650

Comprehensive Client Family Assessment

Demographic Information

Robin is an employed African American female who is 60 years old and is married to her husband of 50 years and they have been married for 15 years. She has three sons and one of them was killed. Robin is referred for stress-related concerns by her employer’s Employee Assistance Program.

Background Information

Identification:

Robin is a Christian she goes to church every Sunday.

History of Present Problem:

Robin states that she needs help as she feels like she is always taken advantage of. This has left her feeling angry most of the time and wondering whether she is just a piece of garbage. Various compiled reasons make her cry up to about five times each week. The stress makes her feel sleepy and tired most of the time and she feels like she is alone and does not have anyone. She also spends a lot of time overthinking about her husband’s issues and his drama. The husband cheated on her and she has been struggling with letting go of the pain and moving past infidelity. Her husband also snorts heroin and this leaves Robin to take care of their financial responsibilities. Robin asked her husband to move out and she has been able to sleep for at least 6 hours since then, compared to the 4 hours she was getting before. Robin admits to gaining weight during the months of winter and being a stress eater.

Past Psychiatric History:

Robin was at the psychiatrist for marital issues in the last 3 months.

Medical History and Conditions:

Thyroid complications of the esophagus. -Back surgery in 2016.

-Neck disc complications -Total knee surgery on the right knee in 2017. -Identified with stage one breast cancer on 2/2019 and had a lumpectomy in June and July 2019. -Diagnosis identified tendinitis in her left foot. - Has stomach ulcers.

Current Medications:

-Lisin0pril

-Gabapentin (nerve pain) -Oxycodone 10mg as needed for pain

Substance Use History:

-Alcohol- first used at 12 years of age and last used on 7/7/19. Characteristically consumes approximately a half red cup of Coconut Rum Cream about 2-3 days every 7 days. -Bhang- experimented as a teenager. -Cocaine and Crack- first used in her late 20s and last used in 2013.

Developmental History:

Robin has difficulties with spelling.

Strengths / Liabilities:

Robin is determined, loving, and great at providing encouragement to other people.

Family Psychiatric History:

The mother’s side has alcoholism running in it while the father’s side includes injection of heroin.

Psychosocial History:

She received the GED in 1984. She is presently working at the DC metro system and has been for one year now. Before that she was working with the City Transportation.

History of Abuse or Trauma:

Robin was a victim of rape when she was 7 years old. Her mother was also an alcoholic and she grew up in a not-so-convenient household with risks of being molested.

Physical and Mental Assessment

General Appearance: Suitable
Dress: Suitable
Motor Activity: Ordinary
Insight: Decent
Judgment: Decent
Affect: Suitable
Mood: Calm
Orientation: X3: Oriented to Person, Place
Memory: Whole
Attention/Concentration: Decent
Thought Content: Suitable
Perception: Common
Flow of Thought: Common
Interview Behavior: Suitable
Speech: Standard

Differential Diagnosis

1. Generalized Anxiety Disorder - Robin does not elicit signs of persistent and excessive worry about things hence this cannot be her condition. She also does not show anticipation of disaster which rules out this diagnosis (Rowa & Antony, 2018).

2. Adjustment Disorder, With Depressed Mood and Anxiety - This is Robin’s condition because she is always feeling sad, hopeless, and tearful. She also feels overwhelmed lacks pleasure in what she previously adored (Baumeister, Maercker, &Casey, 2019).

Treatment Plan

(a) Medication- Medication like Xanax and Neurontin can help with reducing the symptoms of the condition (American Psychiatric Association, 2013).

(a)Cognitive Behavioral Therapy- This will help Robin to learn how to realize and alter destructive thought patterns that negatively influence her emotions and behavior (Baumeister, Maercker, &Casey, 2019). Robin Family Genogram

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Baumeister, H., Maercker, A., & Casey, P. (2009). Adjustment disorder with depressed mood. Psychopathology, 42(3), 139-147.

Rowa, K., & Antony, M. M. (2018). Generalized anxiety disorder.

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Journal Entries

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· Use APA style for your journal entry and references.

Robin’s great grandparents

Robin’s great grandparents

Robin’s parents

Robin’s husband

Robin’s husband

Robin’s children