Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages To Order 5-10 Pages Description/Paper Instructions
Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):
- Treatment modality used and efficacy of approach
- Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)
- Modification(s) of the treatment plan that were made based on progress/lack of progress
- Clinical impressions regarding diagnosis and/or symptoms
- Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
- Safety issues
- Clinical emergencies/actions taken
- Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
- Treatment compliance/lack of compliance
- Clinical consultations
- Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
- Therapist’s recommendations, including whether the client agreed to the recommendations
- Referrals made/reasons for making referrals
- Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
- Issues related to consent and/or informed consent for treatment
- Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
- Information reflecting the therapist’s exercise of clinical judgment
Comprehensive Client Family Assessment
Demographic information: a 28-year-old male Hispanic and working-class (from home due to COVID-19). Works in a warehouse as a call center representative
Presenting Problem: the patient is experiencing reduced ADLs and hygiene and has not been sleeping nor eating for the past few days before the admission to the facility. The patient is also lacking a motive to live, and having suicidal ideation with no plan. These problems have been linked to the recent anxiety and depression which has occurred as a result of working from home due to COVID.
Medical History: the patient states that she is having anxiety and depression that has been caused by working from home due to the emergence of COVID-19. The patient is distracted and showing signs of depression. He has been hospitalized for a mental problem even though he was anxious.
Substance use History: the patient admits to being using alcohol and has been taking marijuana six months ago.
Developmental history: no reported abnormality
Family psychiatric history: Father is deceased, diagnosed with Attention deficit hyperactivity disorder. The mother having a personality disorder.
Psychosocial History: He has been hospitalized for a mental problem even though he stated that he was anxious. He has a history of depression, PTSD, paranoia, anxiety, and pseudo-seizures.
History of the abuse or trauma: the patient stated that he has been sexually abused at the age of 5 years old by their maid. Nevertheless, she never shared the story with another person. She also has a history of post-traumatic stress disorder (PTSD).
Review of the system
Psychiatric: Depression, unspecified bipolar disorder and other related behavior, trauma
Constitutional: No fever nor chills.
Respiratory: No breathing difficulty. No orthopnea.
Cardiovascular: absence of edema.
Gastrointestinal: denies vomiting, nausea, abdominal pain, and constipation
Physical Assessment
Height: 5’8”; weight: 125 pounds; BMI: 18.2 kg/m2; B/P: 110/70; Temperature: 97.8; p 80 R 22
Abdomen: No distension of the abdomen with no axillary and the inguinal lymphadenopathy; non-tender; bowel sounds + × 4 quadrants. No organomegaly. No palpable masses.
Neurological: Cranial nerve is intact i.e. A & O × 3
Cardiovascular: the S1 and S2 rhythm are regular and stable.
Musculoskeletal: the patient is having stable gait
Respiratory: there is a normal chest when percussion is performed. There is bilateral expiratory wheezing.
Mental status examination: the patient is cooperative and is redirectable even though he is having some thoughts. He easily loses attention when he is distracted. He is depressed and having anxiety as a result of working from home. The situation is made worse since he is having some marital issues which increase his level of stress. He admits to being having some suicidal ideation even though he has no plan to implement it. This patient seems to be having some psychosis and this is evident by the fact that he is having auditory and visual hallucinations.
Differential Diagnosis
Anxiety Disorder: this is a condition that is characterized by anxiety or fear that interferes with daily activities. An example of an anxiety disorder is a post-traumatic stress disorder. In this case study, the patient has neglected his ADLs and hygiene. He is also not eating and he is having no motivation in life. The patient is also having a history of the post-traumatic disorder (Karlson et al., 2016).
Suicidal Ideation: this is a mental disorder that has the characteristic of persistent depressed mood and the loss of interest in activities. In this case, the patient is depressed and he has neglected the ADLs and hygiene, not eating, and not sleeping.
Post-traumatic stress disorder: this is a condition that is related to the triggers that can bring memories of the trauma that is characterized by the intense emotional and physical reactions. In this case, the patient has been abused while at the age of five years. She is currently having marital stress which might be the trigger to his current condition. The patient is also not sleeping and having some depressed moods or anxiety as some of the chiefs complain while reporting to the facility.
Schizophrenia: This is a severe mental disorder whereby the victim abnormally interprets the events. It leads to hallucination, delusions, and severely disordered thinking and behaviors that impair functioning and disabling. In the case study, the patient is having both auditory and visual hallucinations. He is neglecting his ADLs, not observing his hygienic condition at the moment, and getting easily distracted. (Chakhssi et al., 2017)
Case formulation
Based on the symptoms presented in the case study, it is clear that the patient might be suffering from the anxiety disorder which is also characterized by the post-traumatic disorder that is being triggered by the marital stress. The anxiety disorder is caused by the fact that he is unable to attend to his jobs in the organization as a result of the COVID-19. He is forced to work from home, something he finds not comfortable with. The problem has forced him not to be further attentive to his ADLs and hygiene. He is losing a focus in his life and he is no longer feeling motivated to live.
The Treatment Plan
The patient is having some issues to be addressed to help him deal with his situation. The patient is currently dealing with issues related to suicidal ideation with no plan of fulfilling it and anxiety. The patient is also having sleeping and eating problem, therefore, the goal of therapeutic approaches, in this case, is to help in the reduction of anxiety, help in addressing the sleeping problem, and to deal with suicidal ideation. Therefore, the therapeutic approach will involve the use of medication and therapy.
Therefore, the treatment will involve the initiation of Seroquel 50 mg at HS for the mania and Prazosin 1 mg at HS for the trauma. The patient is also put under activity therapy by engaging him in a group focus therapy. Activity therapy is also aimed at improving coping skills and managing the moods of the patient.
Part 2: Family Genogram
Paternal Family Maternal Family
Grandparents: both dead, no known history of mental illness
Father: Dead. Was diagnosed with attention deficit hyperactivity disorder (ADHD).
Mother: alive, diagnosed with personality disorder, always and she is showing some strange behaviors
References
Chakhssi, F., Schaap, G., Bohlmeijer, E., & Westerholf, J. G. (2017). Well-being in psychotherapy for individuals with personality disorders. Society for the Advancement of Psychotherapy.
Karlson, B., Johnell, K., Sigstrom, R., & Sjoberg, L. (2016). Depression and depression treatment in a population-based study of individuals over 60 years old without dementia. The American Journal of Geriatric Psychiatry, 24(8), 615-623.
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. The can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. GET THIS PROJECT NOW BY CLICKING ON THIS LINK TO PLACE THE ORDER
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