Comprehensive Client Family Assessment

Practicum Assignment: Case Study: Comprehensive Client Family Assessment

Demographic Information

CB is a 21-year-old female college student in Washington DC

Presenting Problem

CB was having problems with anxiety and depression due to the history of sexual abuse. CB experienced trauma in the context of sexual abuse during her first year of college’s reports trying to do better by focusing on finishing college. According to Wheeler (2013), the feeling of sexual abuse is associated with depression and always makes people go in isolation because they are always anxious about what other people will think of them. She is challenged by her past experiences’ memories and feels ashamed, despite striving to have all her concentration in her college work. She has also bought a new laptop organizer to plan her assignments and even applied for a Fed Ex. She believes that through effective planning and keeping herself occupied will make her forget the memories she does not want to recall. CB states she has improved on depression, but she feels very anxious since she cannot get over the fact that she broke her trust and revealed her sexual assault trauma to family members. The fact that her family is aware of the assault makes her even more anxious, as she strives to overcome the depression.

She has a kid sister and a cousin and admits she is currently not in a good relationship with the mom and her anxiety gets worse whenever she meets the mom. CB’s mom has a history of alcohol abuse, and she does things to her children just for personal gains.CB’s kid, sister, and cousin are also informed that her sexual insult currently suffers from a lack of trust, which has affected her perception of her mom’s good deeds and emotions.CB says it has also increased her anxiety before strangers. Her mom and cousin visited her in school on her 20th birthday, but CB gave her attention, making the mother feel unrecognized; hence her mom got upset and called the security to escort the patient out of the hotel room.

CB is currently at home with her mom and siblings due to schools’ closure related to the covid19 pandemic. She reports that the mom continues to refer to her sexual assault, increasing her anxiety and depression levels. CB feels her mom broke her trust to her sister to make her sad and feel anxious. She is still holding a grudge against her mom and does not understand why her mom would break her trust.CB’s father is not in the picture.

History of Presenting Illness

Patients with a history of sexual assault presented with depression, anxiety, emotional disturbance with no known history of alcohol or drug abuse.

Presenting Signs and Symptoms

Sadness, psychological symptoms of anxiety and depression, crying, anger, and lack of trust.

Precipitating Circumstances

Sexual abuse Alcohol intake by the mom, untrustworthy from the mother, stigma from family and relatives feeling unwanted by the mother.

Past Psychiatric History

There is no history of psychiatric dis

Medical History

CB does not have any medical condition

Substance Abuse History

CB Has No history of substance abuse.

Developmental History

The mom reports no developmental delay

Family Psychiatric History

There is no history of a psychiatric patient in the family.

Psychosocial History

CB fears interacting with people since she does not trust anyone, including her mother.

History of Abuse/Trauma

CB has a history of sexual trauma, which has affected her interaction with people and trust, including the mother

Review of Other Systems

General: the patient is in good health condition, no fever, no weakness, no night sweats, no weightless

Head; No headache, no scope, no dizziness

ENT: No visual disturbance, no hearing deformity, no epistaxis, no teeth problems, no sore throat, no speech difficult

Neck: No neck stiffness, no neck swelling, no masses noted.

Cardiopulmonary: no heart palpitations, no chest pains, no wheezing, denies fatigue, or edema, denies low blood pressure, no hypertension.

GI: no abdominal pain, no vomiting, no nausea, no heartburn, no constipation,

GU: No dysuria, no discharge, no frequency, no urgency, no hematuria, no burning sensation, no incontinence or polyuria

MSS; gait is steady, no backache, no joint pain, no stiffness

Skin: no bleeding, bruises, pruritus, rash, or changes in the hair.

Neuro: No seizures, paralysis, paresthesia, or muscle weakness.

Psychiatric history: depression and anxiety dis s, no mood swings, no use of drugs

Physical Assessment

Vital signs:

Weight-normal,

Height-normal,

BP: 120/82

Temperature; 36.5

Pulse; 78

Appearance: patient appears healthy, not obese, not in apparent respiratory distress symptom,

HENT:

Head: normocephalic

Right Ear: external ear normal

Left Ear: external ear normal

Nose: nose normal

Eyes: EOM are normal, no discharger in both eyes

Neck: Normal range of motion

Cardiovascular: Normal rate

Pulmonary/Chest: Normal effort

Neurological: the patient is alert, normal coordination

Skin: Warm and dry skin. No rshes.no erythema noted. The patient is not diaphoretic, no pallor

Psychiatric: the patient is anxious and disturbed; she is tearful, sad, and agitated; she exhibits a depressive mood; she has sadness inhere speech.

Mental Status Exam

Appearance: Dressed appropriately, clean

Appear stated age and healthy: yes

Eye contact: good

Level of activity: appears calm at first but then starts crying

Gait: Steady

General Behavior: sad, anxious

Speech rate: normal: Volume: normal; Articulation: good

Affect: normal

Mood: depressed, sad, and anxious

Severity: moderate

Concentration: normal

Orientation: normal

Mood: depressed, sad, and anxious

Severity: moderate

Concentration: normal

Differential diagnosis

Depression dis

Generalized anxiety dis

Case Formulation.

Patients with no known comorbidities presented with a history of anxiety and depression. She has a history of sexual assault with episodes of depression and anxiety in meeting strangers. The patient does not trust her mother after telling her sibling on her sexual assault; hence she is feeling depressed and has anxiety. There is no father in question. Mother has misused alcohol in the past.

Treatment Plans

The patient will have treatment plans for therapy in the psychotic department. The treatment will involve a family group three times a visit in a week with the mother being included. The goal is to enable her, the patient, to know that her mother does not have bad intentions; instead, she loves her. She will also be able to access psychiatric education, depression medication, and process group discussion.

Estimated Completion: One Month

Objective #1: CB and her mother to have a healthy relationship.CB’s mother to understand how her child is feeling and apologies for the stigma caused. She should reassure her that she still loves him and has no bad intentions. The family discussion will ensure CB’S feel like the only one having complications.

Objective#2: CB will have a clear view of what’s causing her anxiety episode. She will learn to know that her mother still loves her, and she apologizes for informing the family about her past without her consent.

References

Cantón-Cortés, D., Cortés, M. R., & Cantón, J. (2015). Child sexual abuse, attachment style, and depression: The role of the characteristics of abuse. Journal of interpersonal violence, 30(3), 420-436.

Cole, J., Sprang, G., Lee, R., & Cohen, J. (2016). The trauma of commercial sexual exploitation of youth: A comparison of CSE victims to sexual abuse victims in a clinical sample. Journal of interpersonal violence, 31(1), 122-146.

Wheeler, K. (2013). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. Springer Publishing Company.