Running head: COMPREHENSIVE ASSESSMENT 1
COMPREHENSIVE ASSESSMENT 1
Comprehensive Client Family Assessment and Genogram
Tania Gonzalez Diaz
Walden University
NURS:6640
March 14,2020
Comprehensive Assessment
1. Demographic information: The patient is a 17-year-old black girl. She is escorted by her parents to the clinic after a recommendation from the school counsellor.
2. Presenting problem: According to the father, “our daughter is not feeling well. She has not been attending classes and she tried to commit suicide. We think she is depressed”.
3. History of present illness.: On today visit, patient present awake, alert and oriented, calm, cooperative, organized, with good hygiene. According to the young girl who was ready to share her feelings, she started feeling pressure from schoolwork when she was in her junior year. Her grades were not so good, and she felt useless and that is why she started being a truant. One year later, after starting her senior year, she feels the pressure is too much and she cannot manage to go through the year. One day before being referred to the clinic by the school counsellor, she was found bleeding in the school washroom after she slit her wrist.
4. Past psychiatric history: Since her frustration with school started a year ago, she has never been diagnosed with any psychiatric disorder. The parents though that she was simply going through a phase as a teenager and they were trying to help her cope with school and be a better person. No past psychiatric history. No history of Abuse.
5. Medical history: Despite her recent issue and the fact that she lost her weight suddenly, in the past few months, she is of perfect health. she had asthma and chicken pox when she was young, and she is allergic to penicillin.
6. Substance use history: She has no history of substance abuse. Her parents describe her as a very good girl.
7. Developmental history: Her mother had a successful pregnancy and gave birth to her through normal delivery. She grew up with her older siblings and she achieved all developmental milestones. They have been going to church every Sunday and she is part of the local church youths. Her parents have been married for a while and they are still together. She went through her education as a bright girl until her junior high level when she started failing and missing classes.
8. Family psychiatric history: Her older sister has epilepsy, but her seizures remain under control. There is no other form of psychiatric history in the family
9. Psychosocial history: She has always been an active member of the church youth and they have been doing many activities together since they were in Sunday school. She has also been making many friends from high school but recently, she just wants to be alone
10. History of abuse and trauma: There is no history of abuse or trauma. The parents say that they love and take good care of their daughter and provide everything she wants.
11. Review of systems: She states that she has been feeling sad and irritable all the time. She has not been eating well because of lack of appetite and she finds trouble getting and sustaining sleep. She feels like her life makes no sense because she has been doing very bad in school and she feels bad about it. She denied any heart palpitation, anxiety, sweating or panic attacks. However, she says that she always felt the sense of doom and that is why she went ahead and slit her wrist. HEENT: normal, Respiratory/Chest/Lungs: CTA AP&L: no respiratory problems, no SOB; Breast: Normal, GI: Normal, GU: Normal, Neuro: AAOx3, Endocrine: Normal; Genital/Rectal: Normal condition,
12. Physical assessment: Head and neck are normal. Chest and abdominal examination are normal. No headache, no dizzy, are normal and musculoskeletal examination is normal.
13. Mental status exam: She appears normal and well dressed for the weather. She readily shares her feelings and her shoulders are constantly sagging. She avoids eye contact and expresses guilt for her actions. She has logical judgement and understands the need not to cause harm to herself and the implications to her family. Her perception is normal, and her speech is shaky and traumatized. There are no movement abnormalities.
14. Differential diagnosis: Major depressive disorder, Bipolar disorder, Anxiety disorder
15. Case formulation: The client is a young teenage girl of African American origin. She is 17-year-old and experiencing sadness, worthlessness, hopelessness, fatigue, depressed mood, lack of interest in education and life and she has unsuccessfully attempted suicide. These are symptoms that meet the criteria for diagnosing MDD (American Psychiatric Association, 2013). The stressor for this client is her studies and pressure from family to achieve. In American adolescents, studies have shown that they deal with depression in different ways including aggressive behavior to others and having others reach out (Al-Khattab, Oruche, Perkins & Draucker, 2016). In this case, the client might have attempted suicide for many reasons including as a cry for help. There is need to include the parents in helping her cope with the situation at school. Being an adolescent and a woman might have also increased her susceptibility especially when social support was not enough when she needed it as scholars have established in a research (Van Droogenbroeck, Spruyt & Keppens, 2018).
16. Treatment plan: The client should be started on a cognitive therapy first in order to change her thought process and pattern with a view of promoting positive thinking and changing her behavioral pattern as well (Chand & Arif, 2019). In the case that antidepressants are considered necessary, the parents shall be consulted, and they shall be informed about the risks and benefits of using them before they give consent to any pharmacological treatment. However, CBT should be effective with the support from family and teachers at school.
