PLEASE PAY ATTENTION TO THE ATTACHED INFORMATION ZERO PLAGIARISM 5 REFERENCES NOT MORE THAN 5 YEARS Students will: Assess progress for clients receiving psychotherapy Differentiate progress notes fro

Running head: PRACTICUM ASSESSING CLIENTS 1

Practicum Assessing Clients

Miriane Nguele

Walden University

Practicum Assessing Clients

Demographic Information: The client is a 30-year-old American female who is single and has no kids. The client was born and raised in Maryland, and she has been brought up in the Christian faith, which she subscribes to. The client holds a high school diploma as her highest academic qualification, and currently, the client is unemployed. She says that she recently lost her mother and that experiencing death in the family affects her mental health and eating habits.

Presenting problem: The client reports experiencing anxiety including excessive worry, feeling easily fatigued, feeling on the edge, difficulty concentrating, irritability, muscle tension and disturbed sleep. She also complained of mood disorder including feeling depressed, difficulty falling or staying asleep, isolating self, and overeating until feeling uncomfortably full.

and feeling disgusted and guilty afterward with herself which drives her to binging.

History of Present Illness: The client says that her anxiety and mood disorder makes her feel low at times, it also affects how she socializes with other people, changing her sleeping and eating habits (McQueen & Memedovich, 2017). The other disorder that she is suffering from is an eating disorder, which came as a result of her being criticized for her weight during her days working as a model. The criticism affected her to the point that she is always freaking out about her weight, which makes her binge after eating in fear of gaining weight.

Past Psychiatric History: The client has suffered from an eating disorder anxiety and depression, which she was diagnosed with in the past. The client admits that she was hospitalized a year ago due to depression and an eating disorder. She claims that she has no history of suicidal thoughts or ideas, no history of violence, or self-mutilation. The client says that currently, she is receiving psychiatric treatment from a psychiatric nurse practitioner. She is undergoing psychotherapy at Pathways, which is in Hollywood (Wheeler, 2014). The client accepts that she has been involved in medication trials of Lexapro in the past. Currently, client psychotropic includes Mirtazapine, Klonopin, and Prochlorperazine.

Medical History: The client admits that she was once admitted to for depression and an eating disorder. The client has the following prescription as her medication, Zoloft 25 mg tablet one tablet daily administered orally, Remeron 15 mg tablet, one tablet daily administered orally at night and prochlorperazine maleate 10 mg tablet one tablet daily. The patient claims that she has an allergy to red color on food and medication.

Substance Use History: The client denies any drug or substance use or abuse in her life but admits that she drinks alcohol occasionally.

Developmental History: The client says that she grew up in Maryland, and her parents, especially her mother, took good care of her, and that is why when she died, it affected the client adversely. She says that her parents supported her and provided for her since her childhood and that her development history was excellently felled with love.

Family Psychiatric History: The client claims that her family has no history of medical problems or mental disorders like her.

Psychosocial History: The client claims that she grew up in a suitable environment filled with love and supporting parents. She says that her problem started when she took modeling as a career. During her career, she was criticized for her weight, which made her develop insecurities about her weight and began developing an eating disorder (Bandelow et al., 2017). She has also been experiencing depression and anxiety, which has caused her to be hospitalized.

History of Abuse/Trauma: The client claims that in her life, she has never experienced any type of abuse, only criticism about her weight.

Review of System:

Constitutional

Patient denied chills. Fever. Weakness. Fatigue. Weight Gain or decline in health

Head

Patient denied Dizziness. Headaches. Fainting. Pain.

Cardiovascular

Patient denied Chest Pain. Hair loss on legs. Palpitations. Extremity(s) Cool. Heart Murmur. Extremity(s) Discolored.

Gastrointestinal

Patient reported binge eating. denied Abdominal Pain. Change in stool consistency. Diarrhea. Constipation. Excessive hunger.

Psychiatric

Patient reported anxiety and Depression. Patient denied Behavioral Change. Disturbing Thoughts. Memory Loss. Mood changes. Disorientation. Hallucinations. Nervousness.

Neurological

Patient denied Fainting. Loss of Consciousness. Burning. Head Injury. Dizziness. Headaches. Numbness. Tingling sensation.

Endocrine

Patient denied thyroid problem Cold Intolerance. Goiter. Neck Pain. Excessive Urination. Heat Intolerance. Sweats. Fatigue or Increased Thirst.

Eyes

Patient denied Blurry Vision. Double Vision. Patient denied Cataracts. Excessive Tearing. Discharge. Eye Pain.

Respiratory

Patient denied Bronchitis. Sputum, Short of Breath. Wheezing. Cough.

Musculoskeletal

Patient reported Arthritis. Back Problems. Patient denied Joint Pain. Muscle stiffness. Deformities. Joint Stiffness.

Breasts

Patient denied Discharge. Pain.

Skin

Patient denied Dryness. Hair dye. Easily bruised, Hair texture change. Eczema. Hives.

Hematologic/Lymph

Patient denied Anemia. Bleeding Easily. Blood Clots.

Allergic/Immunologic

Patient denied Coughing. Itchy Eyes. Itchy Nose. Hives. Recurrent Infections.

Mental Status Examination

Alert and oriented, casually dressed, casually grooming, appears to be of the stated age. Was making fair contact. There was no psycho-motor agitation or retardation. Speech was normal in rate, rhythm, tone, and volume. Mood described was anxious and affect was congruent with mood. Thought process was relevant, coherent and goal directed. There were no active responses to delusions, obsessions, compulsions, or phobias. There were no active hallucinations or paranoia. There were no active suicidal or homicidal ideas, intentions, or plans. Impulse control was fair. Insight and judgment were fair.

Differential Diagnosis

Acute Stress Disorder DSM-5 308.3 (F43.0) -Acute stress disorder could be affirmed if the symptoms last from three days to one month after the exposure to the traumatic event. Based on thorough review of the client history and symptoms this diagnosis is not the best fit for this client because client symptom lasted more than one month. Acute stress disorder (ASD) is a mental disorder that can occur in the first month following a trauma. The symptoms that define ASD overlap with those for PTSD. One difference, though, is that a PTSD diagnosis cannot be given until symptoms have lasted for one month. (Hamblen et al, 2019)

Bipolar Disorder DSM-5 296.41 (F31. 11) – clients denied manic or hypomanic episode. Based on thorough review of the client history and symptoms this diagnosis is not the best fit for the client at this time. Bipolar disorder is a chronic or episodic (which means occurring occasionally and at irregular intervals) mental disorder. It can cause unusual, often extreme, and fluctuating changes in mood, energy, activity, and concentration or focus. Bipolar disorder sometimes is called manic-depressive disorder or manic depression, which are older terms. (Brewin et al. 2017)

Drug Induced Mood Disorder DSM-5; ICD-10: (F19.94) clients denied use of drugs or any substance use. Based on thorough review of the on the client history and symptoms this diagnosis is not the best fit for the client at this time. The essential feature of a drug-induced mood disorder is the onset of symptoms in the context of drug use, intoxication, or withdrawal. (Cusack et al, 2016)

DSM-5 Diagnosis:

Major Depressive Disorder 296.31 – The client reports feeling depressed, difficulty falling or staying asleep, isolating self. Based on thorough review of the on the client history and symptoms this diagnosis is appropriate for the client (Association, 2013).

Generalized Anxiety Disorder 300.02 (F41.1) – The client reports excessive worry, feeling easily fatigued, feeling on the edge, difficulty concentrating, irritability, muscle tension and disturbed sleep. Based on thorough review of the on the client history and symptoms this diagnosis is appropriate for the client (Association, 2013).

Binge Eating Disorder: 307.51 (F50.8) Based on thorough review of the on the client history and symptoms this diagnosis is appropriate for the client (Association, 2013)

Case Formulation

The patient is a 30-year-old American female who has a history of depression, anxiety, and an eating disorder. She has experienced episodes of depressive moods, sadness, and anxiety attacks, and due to her fear of gaining weight, she has developed an eating disorder.

Treatment Plan

The client wants to manage her anxiety, depression, and eating disorders, so her treatment will include both medication and psychotherapy. The client is advised to continue seeing her psychiatrist, which will help her deal with depression and anxiety and get good advice on how to prevent adverse effects of the mental disorder and the eating disorder (Vögele et al., 2018). Then she will continue with the prescribed medication Zoloft 25 mg tablet one tablet daily administered orally, Remeron 15 mg tablet, one tablet daily administered orally at night and Prochlorperazine maleate 10 mg tablet one tablet daily. If she experiences any complications with the medications, she should report so that it can be changed to prevent adverse effects.

Part 2 Family Genogram

References

American Psychiatric Association: DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues

in clinical neuroscience, 19(2), 93.

Brewin, C. Cloitre, M., Hyland, P., Shevlin, M., Maercker, A., Bryant, R. A., … Reed, G. M. (2017). A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58, 1–15.

Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., … Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128–141

Hamblen, J. L., Norman, S. B., Sonis, J. H., Phelps, A. J., Bisson, J. I., Nunes, V. D., … Schnurr, P. P. (2019). A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy, 56, 359–

MacQueen, G. M., & Memedovich, K. A. (2017). Cognitive dysfunction in major depression and bipolar disorder: Assessment and treatment options. Psychiatry and clinical neurosciences, 71(1), 18-27.

Marcogliese, E. D., & Vandyk, A. (2019). Mental health nurses’ knowledge of entry-to-practice competencies in psychiatric care. Journal of Continuing Education in Nursing, 50(7), 325–330. doi:10.3928/00220124-20190612-08

Vögele, C., Lutz, A. P., & Gibson, E. L. (2018). Mood, emotions, and eating disorders.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.