WK3- Assignment 2: Practicum – Assessing Clients.

Posted: November 13th, 2022

WK3- Assignment 2: Practicum – Assessing Clients.

Assignment 2: Practicum – Assessing Clients
Learning Objectives
Students will:
Assess clients presenting for psychotherapy
Develop genograms for clients presenting for psychotherapy
To prepare:

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Select a client whom you have observed or counseled at your practicum site.
Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.WK3- Assignment 2: Practicum – Assessing Clients.
The Assignment
Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive ClientAssessment (without violating HIPAA regulations):

Demographic information
Presenting problem
History or present illness
Past psychiatric history
Medical history
Substance use history
Developmental history
Family psychiatric history
Psychosocial history
History of abuse/trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan
Part 2: Family Genogram

Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).WK3- Assignment 2: Practicum – Assessing Clients.

By Day 7 of Week 3
Submit your Assignment.

Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK3Assgn2+last name+first initial.(extension)” as the name.
Click the Week 3 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
Click the Week 3 Assignment 2 link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK3Assgn2+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.WK3- Assignment 2: Practicum – Assessing Clients.
Grading Criteria

To access your rubric:

Week 3 Assignment 2 Rubric
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16638428_1&rubric_id=_1375132_1

Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:

Submit your Week 3 Assignment draft and review the originality report.

Assessing clients
Part 1: Comprehensive client family assessment
Demographic information
Patient’s Name: Esperanza M.
Sex: Female
Date of birth: 1960
Age: 61 years
Religion: Christian Catholic
Ethnicity: Latino/Hispanic
Marital status: Married for 40 years
Children: Two sons
Work Status: Business owner
Preferred Language: High proficiency in English and Hispanic
Presenting problem
Esperanza is a 61 year old woman who is married to a 72 year old man. She has been married for the last 40 years. She has two sons. She co-manages the family business with her husband. She has been referred by her general practitioner for psychiatric care with stress related concerns.
History or present illness.WK3- Assignment 2: Practicum – Assessing Clients.
Esperanza reports that she feels used by her husband and sons. She is particularly critical of her husband who has been engaging in extramarital affairs using the money from the business that they jointly built over the last 35 years. She is also critical of her sons who have largely ignored her unless they want money or help from her. She states that: ‘I feel used by my family … my husband whom I thought would be with me for the rest of my life is slowly drifting away. I have given him the best years of my life and now he feels that I no longer have any use and a younger woman would be preferable. Besides that, my two sons whom I raised with much care have not been much help and have similarly ignored me and my problems.’ The state of affairs has caused Esperanza to exhibit stress related symptoms. Her general practitioner is concerned about the impact of the stress on her overall health.WK3- Assignment 2: Practicum – Assessing Clients.
Past psychiatric history
She has not had any psychiatric concerns although she attended grief therapy sessions more than a decade ago following the death of her parents in a plane crash.
Medical history
She has high blood pressure and is currently on Lisinipril to manage the condition.
Substance use history
She occasionally drinks in social occasions such as family gatherings and business meetings. On average, she takes three glasses of wine every week. She experimented with marijuana and cocaine as a teenager, and has not taken any drugs since she got married.
Developmental history
She does not have any known developmental issues.
Family psychiatric history
She was raised in Mexico City by an alcoholic mother and father. She has two siblings of which one was committed to a psychiatric facility having been diagnosed with depression.WK3- Assignment 2: Practicum – Assessing Clients.
Psychosocial history
She reports that her two sons only talk to her when they have issues and need her help. In addition, her husband mostly ignores her unless there are business issues to be addressed. She has a good relationship with her siblings and talks to them at least once every week.
History of abuse/trauma
She was physically abused by her parents who were alcoholics.
Review of systems
General: Has a straight posture.
Skin: Pallid skin tone.
Head: No history of headaches.
Eyes: Uses prescription glasses to correct vision.
Ears: No vertigo.
Nose: No running nose.
Mouth and Throat: No pain or sores.
Neck: No pain or masses.
Respiratory: No hemoptysis, sputum, wheezing, or cough.
Gatrointenstinal: No black stools, diarrhea, vomiting or nausea.
Genitourinary: No urination urgency or frequency.WK3- Assignment 2: Practicum – Assessing Clients.
Neurologic: No paralysis.
Musculoskeletal: No joint or muscle pain.
Hematologic: No history of anemia or bleeding disorder.
Physical assessment
Vital signs completed: 1:38
B/P: 138/88
Pulse: 82 BPM
RR: 18 BP
Temp: 37oC
Pulse Ox: 96%
Weight: 69 kg
General appearance: Alert appearance.
Skin: No abnormal lesions or moles.
Neck: No masses.
Cardiovascular: Regular rhythm and rate. Some murmurs.
Lungs: No crackles or wheezes.
Mental status exam
Esperanza has an appropriate general appearance, dressing, affect, thought content, and interview behavior. She has good insight, judgment, attention, and concentration. She has normal speech. She has unremarkable motor activity, perception, and flow of thought. She has euthymic mood. She has X3 orientation: is oriented to person, place and time.WK3- Assignment 2: Practicum – Assessing Clients.
Differential diagnosis
Esperanza is diagnosed as suffering from general anxiety disorder (F41.1). She is irritable, nervous, fatigued, restless, and worried; all symptoms that support the diagnosis. The differential diagnosis is adjustment disorder with depressed mood (F43.21). She feels sad, tearful and hopeless; symptoms that support the diagnosis(American Psychiatric Association, 2013; Sperry, 2016).
Case formulation
Esperanza attends the assessment for a diagnosis and treatment plan.
Treatment plan
The patient will receive treatment that will entail attending regularly scheduled psychotherapy sessions that will manage the presented symptoms through guiding the patient in making lifestyle changes, learning coping skills, and applying relaxation techniques. In addition, the psychotherapy will offer emotional support, as well as coping and stress management skills (Wheeler, 2014).  WK3- Assignment 2: Practicum – Assessing Clients.