ASSESSING CLIENT FAMILIES 1
Running Head: ASSESSING CLIENT FAMILIES 1
ASSESSING CLIENT FAMILIES 4
Assessing Client Families
Part One Comprehensive Client Family Assessment
Demographic information: The patient is a 39-year old female of Caucasian origin. Her name is Melissa. She is married to John, a 42-year old man. The two have been married for 10 years and have a daughter called Morgan who is 9 years old. John works as a high school teacher while Melissa is an accountant. For the past 6 months, the couple has been living in a rented single-story home after relocating from Texas. The reason for relocating was to be closer to Melissa’s mother who has two older children, Margaret, and Mandy.
Presenting problem: The reason that the family was seeking therapy is that they had disagreements on whether Melissa should be discharged from the hospital where she was receiving treatment for psychosis. Melissa witnessed the hit and run accident that killed her father when she was 12 years old. Melissa, John, and Melissa’s mother, Louise were the family members present during the session.
History of present illness: The problem started when Melissa failed to pick their daughter from school and instead, she stayed in the car talking to herself. Melissa has a history of hypertension, Bipolar II disorder, and Post-Traumatic Stress Disorder (PTSD) and she had skipped her medication for 2 days.
Past psychiatric history: The patient has a history of both PSTD AND Bipolar II Disorder which have been controlled using medication.
Medical history: Melissa has a history of hypertension and she is up to date with all immunizations. She has no allergies, no surgical history, and her last physical exam was 2 years ago.
Substance use history: None.
Developmental history: Melissa was raised by a single mother after the death of her father. She was delivered normally with no complications.
Family psychiatric history: None
Psychosocial history: Melissa works a full-time job and lives with her husband and daughter.
History of abuse and/or trauma: The patient witnessed her father being killed in a hit and run accident. She reports no physical, sexual, or emotional abuse.
Review of systems: Melissa has a history of hypertension. And reports no other medical history.
Physical assessment: Melissa appears physically healthy.
Mental status exam: Melissa is alert but has poor insight into her condition.
Differential diagnosis: Melissa was diagnosed with “PTSD 309.81 (F43.10) and bipolar II disorder (BD) 296.89 (F31.81).”
Case formulation: Melissa was experiencing auditory hallucinations which led to her admission to the psychiatric unit. Shed did not have any other symptoms. After some time, she requested to be discharged to which her husband and the doctor declined.
Treatment plan: The goal of the treatment was to convince Melissa to stay at the hospital and to continue with inpatient care. She agreed to stay until the doctor confirmed that she was fit to go home. She also agreed to group therapy and medication. She was also given access to a phone to communicate with her daughter. John’s MSE: John appeared calm and composed. He spoke in a normal tone and was coherent. He was attentive and did not lose his though process. He had insight into the condition of his wife. Louise’s MSE: Louise was logical, goal-oriented, and has fair insight into the condition of her daughter.
Part Two: Family Genogram
References
Kurpad, S. S. (2018). Ethics in psychosocial interventions. Indian Journal of Psychiatry, 60(4), 571-574. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_26_18
Norris, D. R., Clark, M. S., & Shipley, S. (2016). The mental status examination. American Family Physician, 94(8), 636-641. Retrieved from www.aafp.org/afp
