Comprehensive Client Family Assessment

Demographic Information

Date of assessment: 09/14/2018. DOB: 011/01/1970. Age: 48. Race: Black.

SSN: 000000001. Ethnicity: African American. Address: On file. Tel: 972-000-0000.

Residential Status: Homeless. County: 9K. Military Status: None.

Language: English. Interpreter Needed: No. Primary Insurance: Uninsured.

Annual Gross Income: $0. Employment Status: Unemployed.

Number of people in the household: 1. Highest Grade: 11.

School Attendance for the past 3 Months: None.

Arrival Time: 1000 Time Disposition Completed: 1100

Location of client: Lake Worth Nursing Home

Presenting Problem

“My meds are not working.”

History of Present Illness

The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife. The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013).

Past psychiatric history

1- Major Depressive disorder, Recurrent Episode with psychotic features

2- Alcohol use disorder; severe

3- Bipolar I Disorder most recent episode depressed Severe

Medical history

None Reported

Substance use history

Alcohol Abuse: began drinking at age 15 and drinks 8 to 10 bottles of beer daily, yesterday was his last time he drank.

Developmental history

None Reported

Family psychiatric history

Positive for family history of mental illness on the paternal side.

Psychosocial history

The patient is unemployed and enjoys hanging out with fellow drunkards on the street with drinks, a living condition currently unstable as the patient is homeless.

History of abuse/trauma

The patient suffered abuse paternal uncle at age 12.

Review of systems

General: significant weight gain recently, positive with fatigue, but no fever or a cough.

HEENT: vision and hearing changes not reported at this time, no history of glaucoma, cataracts, diplopia, floaters, excessive tearing or photophobia, last eye exam four years ago. No ear infections, tinnitus or discharges in the ear, have no problems with smell, and taste. Denies epistaxis or nasal drainage, no any loose teeth, mouth sores or bleeding gum when brushing teeth. No difficulty with chewing or swallowing.

Neck: positive for JVD, no bruits

Respiratory: Denies shortness of breath, labored breathing, cough, but could be exposed to TB.

Cardiovascular: S1 and S2, RRR. No Shortness of breath reported, denies chest pain, palpitations, No difficulty during exercise.

GI: No nausea, vomiting, heartburn, indigestion.  No changes in bowel/bladder pattern, bowel sounds present on all four quadrants.

GU: No change in urinary pattern, hematuria or dysuria.

Musculoskeletal: WNL, No joint pain or swelling.

Psych: Positive for the history of mental health, reports anxiety, depression suicidal ideation but no homicidal thoughts.

Neuro: Alert, oriented x 3, no fainting, dizziness, or loss of coordination, positive for weakness.

Skin: warm to touch and moist, denies any skin changes, rashes or raised lesions, no itching, no history of skin disorders or cancers, no swelling.

Hematologic: No bleeding disorders or clotting issues, no history of anemia or blood transfusions.

Allergic/Immunologic: Penicillin- rash and seasonal allergies, Sulfa drugs – rash.

Physical assessment

Vital signs: B/P 130/78; P 70 regular; T 98.4 orally; RR 20 non-labored; RBS 100mgdl; Wt: 140 lbs.; Ht: 5’6; BMI 22.6.

Mental status exam

The level of consciousness: cerebral perfusion, coherent thought, concise responses.

Mood: Depressed and sad.

Behavior: Appropriate/Normal and cooperative.

Cognition: displays signs of hallucination and compulsion.

Personal hygiene and grooming: deteriorated grooming and personal hygiene.

Memory and attention: AO x 3.

Differential diagnosis

1- Major Depressive disorder, Recurrent Episode with psychotic features

2- Alcohol use disorder; severe

3- Bipolar I Disorder most recent episode depressed Severe

4- Recurrent Episode with psychotic features (DSM-5, 2018).

Columbia Suicide Severity Rating Scale:

1- Wish to be dead: Yes

2- Suicidal thoughts: yes

3- Suicidal thoughts with method (with a specific plan and intend to act): Yes

4- Suicidal Intend (with particular plan): Yes

5- Suicidal Intend with a specific plan; Yes

6- Suicidal behavior question: Yes

If yes to 6, how long ago did you do any of these: Over a year ago (American Psychiatric Association, 2013).

Case formulation

The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife. The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013).

Treatment plan

The client will begin an antidepressant Sertraline (Zoloft) 25 mg PO daily for the next four week and monitor progress. Start patient on an alcohol detox program to help with dependency and encourage to client join the alcohol anonymous (AA) group for support (Wheeler, K., 2014).