Week 3Assignment 2 Practicum – Assessing ClientsName Amina.docx

Week 3
Assignment 2: Practicum – Assessing Clients

Name: Amina. H
DOB; 1/10/1987
Age: 32
Gender : Female
Race: Black or African American
Facility: REH Crisis Stabilization Program
City: Minneapolis State: MN
Presenting problem- Excessive alcohol use, Homelessness
History or present illness
Amina is a Somali immigrant that left the war-torn country. She is experiencing an increase in mental health symptoms and stress, especially anxiety and other trauma-related stress. Having difficulty with connecting to other people due to several trauma-related symptoms and Currently homeless. Amina is required by CPS to remain sober and enter treatment in order to maintain custody of her six kids.
Past psychiatric history
Amina has indicated that When under the influence of alcohol, Amina has gotten into fights at times. She is currently not using alcohol, and is requesting to be administered UA's or breathalyzers to verify that she is not using alcohol.
Amina has endorsed racing thoughts and rumination, paranoia/fear, dissociation, difficulty staying asleep, nightmares, negative cognitions of self, others, and the world; crying episodes, depressed mood, heightened startle response, shakiness, and irritability

Medical history
Client denies syncope, lightshades, fever, or numbness or tingling States that her generalized pain is 8/10. administered 400mg of Ibuprofen.
Substance use history
Amina reported that she has had more than 10 years history of over using alcohol, and she seeking to enter Substance use treatment for alcohol
Developmental history
No history available. Patient is an immigrant from Somalia
Family psychiatric history
No history available
History of abuse/trauma
Amina has endorsed persistent worrying that is difficult to control, experience of war, experience of childhood physical abuse,
Review of Systems:
General: Denies fever chills or malaise, Denies weakness or fatigue. Client is alert and oriented to person, place, and time as well as to situation. Client weighs 176 lbs. but client expresses her ideal weight to be 140lbs
Skin, Hair Nails: No problems reported

HEENT- denies a headache, dizziness, or syncope. Denies any hearing issues, denies tinnitus. Denies problems or changes in his vision; denies blurred vision; denies seeing spots.

Cardiovascular: BP 124/104 on left arm sitting and 156/108 on right arm sitting. HR regular and at 97 beats per minute. Denies chest pain and palpitations

Pulmonary: Oxygen saturation 98%. Denies asthma or any other pulmonary disorder. Denies shortness of breath; respirations 16.

Gastrointestinal: Bowel is regular

Genitourinary: Regular urinary pattern

Neurologic: Client informs that she was diagnosed with polio when she was 7. Denies numbness and tingling; or paresthesia

Musculoskeletal– Client informs that she was diagnosed with polio when she was 7. Patient states that she has generalized aches and pains.
Hematology: Denies easy bruising or history of anemia
Endocrine: ...

1. Week 3
Assignment 2: Practicum – Assessing Clients

Name: Amina. H
DOB; 1/10/1987
Age: 32
Gender : Female
Race: Black or African American
Facility: REH Crisis Stabilization Program
City: Minneapolis State: MN
Presenting problem- Excessive alcohol use, Homelessness
History or present illness
Amina is a Somali immigrant that left the war-torn country. She
is experiencing an increase in mental health symptoms and
stress, especially anxiety and other trauma-related stress.
Having difficulty with connecting to other people due to several
trauma-related symptoms and Currently homeless. Amina is
required by CPS to remain sober and enter treatment in order to
maintain custody of her six kids.
Past psychiatric history
Amina has indicated that When under the influence of alcohol,
Amina has gotten into fights at times. She is currently not using
alcohol, and is requesting to be administered UA's or
breathalyzers to verify that she is not using alcohol.
Amina has endorsed racing thoughts and rumination,
paranoia/fear, dissociation, difficulty staying asleep,
nightmares, negative cognitions of self, others, and the world;
crying episodes, depressed mood, heightened startle response,
shakiness, and irritability

Medical history
Client denies syncope, lightshades, fever, or numbness or
tingling States that her generalized pain is 8/10. administered
400mg of Ibuprofen.

2. Substance use history
Amina reported that she has had more than 10 years history of
over using alcohol, and she seeking to enter Substance use
treatment for alcohol
Developmental history
No history available. Patient is an immigrant from Somalia
Family psychiatric history
No history available
History of abuse/trauma
Amina has endorsed persistent worrying that is difficult to
control, experience of war, experience of childhood physical
abuse,
Review of Systems:
General: Denies fever chills or malaise, Denies weakness or
fatigue. Client is alert and oriented to person, place, and time as
well as to situation. Client weighs 176 lbs. but client expresses
her ideal weight to be 140lbs
Skin, Hair Nails: No problems reported

HEENT- denies a headache, dizziness, or syncope. Denies any
hearing issues, denies tinnitus. Denies problems or changes in
his vision; denies blurred vision; denies seeing spots.

Cardiovascular: BP 124/104 on left arm sitting and 156/108 on
right arm sitting. HR regular and at 97 beats per minute. Denies
chest pain and palpitations

Pulmonary: Oxygen saturation 98%. Denies asthma or any other
pulmonary disorder. Denies shortness of breath; respirations 16.

Gastrointestinal: Bowel is regular

Genitourinary: Regular urinary pattern

Neurologic: Client informs that she was diagnosed with polio
when she was 7. Denies numbness and tingling; or paresthesia

3. Musculoskeletal– Client informs that she was diagnosed with
polio when she was 7. Patient states that she has generalized
aches and pains.
Hematology: Denies easy bruising or history of anemia
Endocrine: Denies increase thirst or urination,
Mental Health:Mental status exam
Amina presented cooperative during the clinical interview. Her
eye contact is poor. Speech is clear, coherent, but tangential at
times. Speaks broken English. She makes no unusual motor
movements and demonstrates no tic. Mood was dysphoric.
Affect however is restricted. She denies visual or auditory
hallucinations. No delusional or paranoid thought processes
noted. She is alert and oriented to person, place, and time. She
reported that there were six children and she is estranged from
them due to her excessive alcohol use. She reported depression
and has a noticeable restrained affect, with an occasional smile.
She denies visual or auditory hallucination, and her thought
process is intact. The client’s awareness is age appropriate and
associated with proper judgment and understanding. She denies
current suicidal ideation. The diagnostic test of Patient Health
Questionnaire-9 (PHQ-9) was administered to the client. The
score was 16, which indicates severe depression.
Differential diagnosis
Depression, Post Traumatic Stress Disorder (PTSD), Alcohol
Use Disorder
Case formulation
Drawing up from psychiatric viewpoint, the premise of Amina
issues may have result from been a witness and experience of
war, and extensive childhood physical abuse, and overall the
family is not supportive, and lost custody of her children. Her
presentation is congruent with reported content.
Treatment plan
Goal #1
Amina will be able to reduce and manage her anxiety

4. Objective
Amina will develop her coping skills, and build on her current
coping approaches of breathing, prayer, and self-soothing
techniques such as taking a walk.

Intervention
Staff will check in with Amina 2-3 times to assess her practice
of coping skills, and to offer information regarding additional
coping skills including progressive muscle relaxation,
visualization, assertive communication of her feelings.

Goal #2
Amina will attend her therapy sessions

Objective
Amina will continue her sessions with the trauma-informed
therapist, with an upcoming appointment next week.

Intervention

Staff will process current feeling about what to expect and how
she is feeling about the appointment.

Goal #3
Amina will complete a substance use disorder (SUD) treatment.
Objective
Amina will complete rule 25 assessment to be able to gain
admission into treatment center at Park Ave Women's center.

Intervention
Staff will encourage Amina to attend her assessment session and
develop a relapse prevention plan.

Genogram

5. Amina’s children’s ages-2,3,5, 7,8,9
Amina is estranged from her husband and children
Amina does not have any extended family in the US