The Assignment

Document the following for the family in the video, using the Comprehensive Evaluation Note Template:

• Chief complaint
• History of present illness
• Past psychiatric history
• Substance use history
• Family psychiatric/substance use history
• Psychosocial history/Developmental history
• Medical history
• Review of systems (ROS)
• Physical assessment (if applicable)
• Mental status exam
• Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
• Case formulation and treatment plan
• Include a psychotherapy genogram for the family

Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.

Solution: NRNP-6645 Week 2 Assignment: Family Assessment

NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation Note Template

Introduction

The family conflict involves discord, bitterness, disputes inside the family structure, and, if left unresolved, can result in disorder. Family conflict is correlated with dysfunction in multiple areas, including social and parental dysfunction. Moreover, the family case pertains to the recognition of two distinct cultures from the children’s point of view. The paper aims to examine the family dispute and provide differential diagnoses.

CC (chief complaint): “So ever since she came here chaos was created inside the household.”

HPI: P.P., a 45-year-old Iranian female, is being evaluated at the request of her family therapist, Sandi, to better understand the complex trauma and family dynamics impacting the patient and her children. P.P. immigrated to the United States 12 years ago with 4 of her 5 children, leaving her then 8-year-old daughter Shireen behind in their home country Iran. This separation was due to the family’s history of domestic violence, with P.P. and her children escaping an abusive household. Two years ago, P.P. was finally able to bring Shireen to the US, but this reunion has had significant challenges. P.P. reports that since Shireen’s arrival, the household has been in “chaos” as Shireen struggles to adjust to life in America and her siblings’ more Westernized ways. It was recently revealed that during the years Shireen was left behind, she was sexually assaulted by her father. This trauma, compounded by the family’s immigration experience and history of domestic violence, has placed immense strain on P.P. and her children as they try to make sense of their bicultural identity. In addition, P.P. has recently undergone two failed foot surgeries, leaving her disabled, in constant pain, and unable to work. This has created additional financial and emotional stress for the family. P.P. denies any current suicidal or homicidal ideation, but reports feeling overwhelmed, anxious, and depressed at times due to the accumulation of traumas and difficulties in the household. The family has been in therapy with Sandi for approximately 18 months, though Shireen has been resistant to engaging in treatment. P.P. reports a desire to find stability and healing for herself and her family. She is having a difficult time adjusting to her disabled status, inability to work, loss of independence, and lack of control over her now adult children whose values and lifestyle choices increasingly diverge from her own beliefs and expectations.

Past Psychiatric History:

• General Statement: She has a significant history of trauma and mental health challenges from her experience of domestic violence and immigration. She states that she is lonely and depressed without her children around her.
• Caregivers (if applicable): None
• Hospitalizations: She has had two recent foot surgeries but no psychiatric hospitalization.
• Medication trials: She is not currently prescribed any psychotropic medications, though she may have been prescribed anti-anxiety or antidepressant medications in the past to manage the symptoms related to her trauma and family stressors.
• Psychotherapy or Previous Psychiatric Diagnosis: P.P. and her family have been engaged in family therapy with their therapist, Sandi, for approximately 18 months. However, there is no indication of any previous formal psychiatric diagnoses for P.P. The focus of the therapy has been on addressing the complex trauma, family dynamics, and cultural differences.

Substance Current Use and History: The video does not provide any information about P.P.’s current or past substance use. To gather this information, I would ask P.P. directly about her use of alcohol, tobacco, illicit drugs, or prescription medications (other than those prescribed). It is important to understand if she has any active substance use issues, as this can significantly impact her mental health, functioning, and treatment plan. A history of substance use would also be relevant to explore, as it may be related to her past traumatic experiences or coping mechanisms.

Family Psychiatric/Substance Use History: P.P.’s family has a significant history of trauma, including domestic violence and child sexual abuse. It is noted that P.P.’s 21-year-old daughter, Shireen, was sexually assaulted by the father while P.P. and the other children were in the process of immigrating to the US….Please click purchase button below to get full answer for $15

Related: (Solution) NRNP-6645 Week 3 Assignment