Assignment 2: Practicum – Assessing Client Progress

ASSIGNMENT 2: PRACTICUM – ASSESSING CLIENTS 1

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ASSIGNMENT 2: PRACTICUM – ASSESSING CLIENTS

Assignment 2: Practicum – Assessing Clients

Part 1: Comprehensive Client Family Assessment

Demographic information: T.C is a 73 years old African American male who was admitted after being discharged from another local hospital. Assignment 2: Practicum – Assessing Client Progress

Presenting problem: The patient’s present problem is increased psychosis with auditory hallucination (AH).

History or present illness: The patient has a history of multiple hospitalizations, of which he refused to give further details. He was however diagnosed with increased psychosis with auditory hallucination and reports of being capable of hurting himself and others. He was planning to harm himself with an ice pick on the neck. He claims that he has been having auditory hallucinations telling him to harm himself. He was unable to state the onset of the symptoms of the presenting illness. He was not cooperating with the clinician.

Past psychiatric history: The patient has a history of multiple hospitalizations, which he refused to discuss further.

Diagnoses: Chronic mental illness

Suicidal gestures or attempts: None

Medical history: Cerebrovascular accident (CVA), Hypertension (HTN), chronic obstructive pulmonary disease(COPD), Seizure, Congestive heart failure (CHF).

Surgical history: None

Allergies: No known drug allergies

Current Medication:

· Aspirin oral 81 mg TC, PO daily for the management of CAD

· Rivaroxaban oral 10mg tablets PO daily for the management of CAV/MI

Substance use history: The patient claims to be using cocaine as much as he can, once a month. He claims to have started using the drug when he was 19 years old. He, however, refused to give the last day that he used the drug. He also smokes marijuana once a day and started using it when he was 17 years old. He smokes cigarettes at least 3 to 4 times a day.

Developmental history: The patient is a 73-year-old African American male. He is homeless. He is a Christian. His past daily activities include playing soccer and taking an active role in community services. All his early motor, social, language in addition to emotional milestones were within normal limits before being diagnosed with a psychological disorder.

Family psychiatric history: Negative family psychiatric history. There is no known history of any of the family members suffering from any psychiatric disorder, or under psychiatric medications or hospitalization. No other family member has ever displayed suicidal behavior or substance abuse.

Psychosocial history: The patient has a history of chronic mental illness and is non-compliant to medical treatment.

History of abuse/trauma: The patient has no reported history of abuse or trauma.

Review of systems:

General: No weight change, generally appears to be confused. He presented with poor insight and unable to respond to most questions during an assessment. He does not exercise as much as he used to.

Skin: He denies any changes in his skin, pruritis, rash, or changes in hair color.

Head: The patient is positive for occasional migraine headaches.

Neck: He denies neck swelling, stiffness or pain.

ENT: Ears: No change in hearing, no tinnitus, no vertigo. Nose: No epistaxis, no discharge. Mouth: Yellow colored teeth. No gingival bleeding, no use of dentures. Oropharynx: no erythema or exudates and no enlargement of tonsils.

Chest: Experiences shortness of breath sometimes with dry cough. He denies wheezing.

Cardiovascular: Denies chest pains, palpitations, syncope or orthopnea.

Abdomen: Complains of decreased appetite. Denies abdominal pains, or bowel habit changes.

Gastrointestinal: Denies nausea, vomiting, vomiting, regurgitation;

Genitourinary: Denies urinary urgency, dysuria, and change in the nature of urine.

Hematologic: Denies bleeding, bruises or anemia.

Lymphatics: No history of enlarged lymph nodes or splenomegaly

Endocrinologic: Denies changes in hair or skin color, polydipsia, polyuria or polyphagia.

Musculoskeletal: Denies pain in muscles or joints, limitation of range of motion, paresthesia or numbness.

Neurologic: Complains of general body weakness. Denies tremors and ataxia. Has a history of seizures.

Psychiatric: Patient has a history of chronic mental illness. He, however, denies hallucination, delusion, or suicidal thoughts. He was however diagnosed with increased psychosis with auditory hallucination and harm to self and others.

Physical assessment

Height:

Weight:

Temp:

RR:

BP:

Pulse:

Appearance: He appears poorly groomed, and unhygienic. He seems to be very anxious and unresponsive to the questions asked during physical examination. He is also glum and inattentive. He is somehow sad, littles and depressed. The slowness of his physical movement helped reveal a depressed mood. His facial expressions also revealed a sad and depressed mood. Generally, he looks hopeless.

Mental status exam:

· Appearance: the patient has a disheveled and unkempt appearance, with poor eye contact and paranoid.

· Motor activity: the patient is restless with excessive motor activities such as pacing, inability to sit still and wringing of hands (Smith, Johns, & Mitchell, 2017).

· Speech: The patient is withdrawn, and talks very slowly only when he feels like talking.

· Mood and Affect: Patient seems to be in a depressed hopeless mood.

· Thoughts: The patient is delusional and thinks of harming himself and others.

· Perceptual distribution: The patients complain of auditory hallucination.

· Sensorium and cognition: The patients lose concentration several times during physical examination (Smith, Johns, & Mitchell, 2017).

· Insight: The patient is aware of his ills but noncompliant to previous medication.

· Judgment: The patient is of poor judgment.

Differential diagnosis (Griswold, Del, & Berger, 2015):

· Opioid use, unspecified with opioid-induced psychotic disorder with hallucinations (F11.951):

· Alcohol dependence with alcohol-induced psychotic disorder with hallucinations (F10.251):

· Auditory hallucinations (R44.0):

Case formulation:

Based on the patient history, physical and mental examination findings, the patient is most likely suffering from increased psychosis with auditory hallucination. He reports having auditory hallucinations telling him to harm himself and others. He also has a history of chronic mental illness of which he was noncompliant to medication. He is homeless and has no one to take care of him. He has been using cocaine, marijuana, and been cigarette smoking for several years, and does not seem to quit. According to the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM-5), substance-induced psychotic disorder is diagnosed base on the presence of either one or both of the following symptoms, delusion, and hallucination, and evidence of both delusion or hallucination immediately after substance intoxication or withdrawal or after exposure to the drug (Munjampalli & Davis, 2016). As a result, the patient’s mental condition might have been as a result of drug abuse. Hence, he is most likely suffering from opioid-induced psychosis with hallucination. However, excessive use of alcohol can also lead to hallucination and with alcohol dependence, the individual can develop psychosis (Sivanesan, Gitlin, & Candiotti, 2017). Thus, alcohol dependence with alcohol-induced psychotic disorder with hallucination is also a possible diagnosis.

Treatment plan

In most cases, hallucinations do not necessarily need pharmacotherapy if the experience is not intrusive and does not interfere with others. However, in the above case study, the patient has proven the potential of causing harm to himself and others. As such, the best treatment of choice is the use of antipsychotic medication. However, the clinician is expected to discuss with the patient all the benefits and adverse effects of each drug including the possibilities of the drugs to cause symptoms such as metabolic and extrapyramidal syndrome (Hayward, 2018). Consequently, the clinician is expected to monitor the physical health of the patient on a regular basis. In the above case scenario, T.C needs to continue using the prescribed medications to manage his symptoms as follows:

· Mood/anxiety/sleep: Administer 200mg quetiapine oral tablets once a day at bedtime for 6 months.

· Mood: After 4 weeks, when the patient is compliant, lower the dose of quetiapine oral tablets to 100mg every morning for three months.

· Insomnia: Two months later, to control insomnia, start the patient on mirtazapine oral 15mg tablets at bedtime every night.

· Mood: two months later, the patient should reduce the dose of quetiapine oral to 50 mg tablets, each tablet every morning.

· During the following month’s visit, start the patient on clonazepam oral 1 mg tablets twice per day to manage anxiety.

· If the patient’s symptoms still persist, increase the dose of quetiapine to 300 mg orally every bedtime.

Additionally, the patient should be enrolled in a psychological treatment plan. Most studies show that some patients may be more responsive to cognitive behavioral therapy more than pharmacotherapy (Hayward, 2018). Psychotherapy will focus more on evaluating and monitoring the patient’s perception, beliefs, and reasoning and promote alternative ways of coping with the symptoms and reduce stress.

Lastly, peer support group is also necessary as it will help the patient alleviate the impact of voice. Self-help groups help patients take responsibility for their hallucinatory experience, accept and cope with the voices (Slotema, Blom, Niemantsverdriet, & Sommer, 2018). With the above interventions, the patient’s symptoms will be controlled appropriately. Assignment 2: Practicum – Assessing Client Progress

 

Part 2: Family Genogram for T.C

 

 

Child SN

Child PN

Child GT

Child HT

Child TL

Child BL

Child TC

Child QC

 

 

 

Parent ON

Parent LC

Parent HL

Parent JT

 

 

 

 

Great grand Parent C M

Grand Parent ML

Grand Parent NL

 

References

Griswold, K. S., Del, R. P. A., & Berger, R. C. (January 01, 2015). Recognition and differential diagnosis of psychosis in primary care. American Family Physician, 91(12), 856-863.

Hayward, M. (May 01, 2018). Evidence-based psychological approaches for auditory hallucinations: Commentary On… Auditory Hallucinations in Schizophrenia. Bjpsych Advances, 24(3), 174-177.

Munjampalli, S. K., & Davis, D. E. (January 01, 2016). Medicinal-Induced Behavior Disorders. Neurologic Clinics, 34(1), 133-169.

Sivanesan, E., Gitlin, M. C., & Candiotti, K. A. (January 01, 2017). Opioid-Induced Hallucinations: A Review of the Literature, Pathophysiology, Diagnosis, and Treatment. Survey of Anesthesiology, 61(1), 21-21.

Slotema, C. W., Blom, J. D., Niemantsverdriet, M. B. A., & Sommer, I. E. C. (2018). Auditory Verbal Hallucinations in Borderline Personality Disorder and the Efficacy of Antipsychotics: A Systematic Review.

Smith, L. M., Johns, L. C., Johns, L. C., & Mitchell, R. L. C. (September 01, 2017). Characterizing the experience of auditory verbal hallucinations and accompanying delusions in individuals with a diagnosis of bipolar disorder: A systematic review. Bipolar Disorders, 19(6), 417-433.