Assessment | NURS 6640 – Psychotherapy With Individuals | Walden University

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Patient is 57 years old AAF, who was seen today in the clinic. patient reports living with an abusive husband who physically beats her. Pt report her husband was suspecting that she was going out with someone at her job.PT report sustaining concussion from her husband beating one time, report history of broken nose, black eye and lacerated head from his beating. Pt report all these happened 2019. Patient is no longer living together with Husband, refer husbands as EX. Denied suicidal intent or plan , admits visual hallucinations of seeing shadow of her husband who is not living with him hovering over her head, report these makes her not to sleep. Pt report auditory hallucination of  her husband whispering to her that he will be back, Pt report these happen almost every two days. Pt report hearing her husband said he will beat her to a point  nobody will want to be with her. Patient report visual and auditory hallucination of her husband started when she moved from Pennsylvania to Maryland in October 2019. Patient report taking Alprazolam 1mg PO QD, prescribed by PCP. Patient feeling depressed, trouble sleeping and staying asleep, felling bad about self, trouble concentrating on things, restlessness and worrying too much. Patient report poor appetite. Patient denied moment of sustained anger. 

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).

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