Practicum – Assessing Client Progress.

Assignment 2: Practicum – Assessing Client Progress

Subjective

“I wonder when this jumpiness will come to an end or if symptoms of apprehensiveness will ever be effectively controlled” Practicum – Assessing Client Progress.

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The client states that she continues to have sleeping problems and that she sleep is neither continuous nor restful. She reports having elevated feelings of muscular tension over the neck. The client reports that she always feels irritable and has difficulties with concentrating and paying attention. She states that she does not like socializing and if she does she forces herself to socialize. She also reports of having recurrent headaches and muscle stiffness. She admits being anxious and feeling overwhelmed even when performing the easiest task and becomes easily frustrated. The client denies any suicidal thoughts or any self-harmbehavior. She also denies alcohol intake or substance abuse. However, she reported that latterly she is addicted to nicotine and caffeine and her apprehensiveness increases if does not take caffeine.

Objective

Allergies: Contact dermatitis

Medications

• Buspirone 10 mg PO QAM
• Synthroid 50 mcg PO QAM

Suicide Risk Assessment: Low risk of suicide

The client is a 37-year-old female, whose appearance appears appropriate for her age. She appears calm but she is fidgety and manifests signs of anxiety as manifested by signs such as jumpiness, restlessness and muscle tension.

Vitals: HR: 77; Sat: 98%; weight 65 kg; BP: 146/92 mmHg (hypertension); muscle tension with palpation; increased kyphosis; the client appears to be sweating and her hands are clammy to touch.

Assessment

MENTAL STATUS EXAMINATION:The client is irritable, easily distracted, well groomed, fully communicative, and seems anxious. Her speech appears normal in volume, coherence and articulation. She exhibits intact language skills. Her mood appears normal without any sign of sadness or elevated moods. The client’s affect is congruent with her mood. She does not exhibit any sign of hallucinations or any other indicator of psychosis. She is well oriented to time and place. Her thought process is normal and intact, thinking logical and associations intact.No ideation or intent to commit suicide. The client’s cognitive functioning is normally and age appropriate. Her memory is intact as manifested by her ability to abstract and perform calculations. Her IQ appears to be more than average.

GAD-7 = 12/21
Penn State Worry Questionnaire = 50/80

Diagnostic Impression according to the DSM-5 Criteria: Generalized Anxiety Disorder

Treatment Plan

• Obtaining informed consent from the client
• Since the assessment data and the outcome measures indicate that the client has signs consistent with a moderately severe type of generalized anxiety disorder, the recommended treatment will include a combination of medication and psychotherapy (cognitive behavioral therapy, CBT) (Khdour et al, 2016).
• Medication therapy will consist ofPaxil 10 mg and Ambien CR 6.25 mg and discontinuation of previous prescription(Crits-Christoph et al, 2017).
• CBT treatment will include 15 sessions of CBT where it is expected that the client will display major symptom reduction after 10 sessions. The first 2 sessions will be relaxation training where the client will be taught about how to relax. The 3-5 will include cognitive restructuring where the client will be educated on how to examine the unhelpful thinking patterns and learn new efficient thinking patterns. The 6-9 sessions will include mindfulness training where the client will be trained on how to focus which will be helpful in addressing her lack of concentration. The other remaining sessions will focus on systematic exposure and problem-solving training (Hofmann et al, 2014) Practicum – Assessing Client Progress.
• Education: The client will be provided educational information regarding anxiety management that the client can use apart from the therapy. The client will be taught stress management practices like mediation, deep breathing exercises, as well as muscle relaxation exercises. The client will also be referred to a self-group or a support group.
• Finally family support will also be included in order to facilitate the client’s recovery. The family will be informed that GAD is a very serious disorder and very real to the client and hence the family should not underestimate the condition or expect instant improvement for the client (Locke et al, 2015).
• Client will be educated on medication adherence and side effects of the prescribed medications
• Client to attend clinical review after two weeks

Treatment Goals

• Short Term Goals: The client’s anxiety symptoms will reduce by 50% by the end of the first month
• Long Term Goal(s): Symptoms of GAD will reduce as manifested by reduced occurrence and intensity of the anxiety. The client will manifest elevated self-confidence within 3 months

Privilege Note

The client was cooperative throughout the session but she I noted that she is very stressed regarding her diagnosis. She is not so much willing to get treatment because she is even ready to give up on treatment because she somehow believes her symptoms will not go away any time soon. The client seems to have low self-esteem which might be a contributing factor to her condition. She rarely mentions her family members and it really took time to convince her regarding the relevance of informing the family about her diagnosis and including them in the treatment plan. I have a feeling the client is not receiving adequate support from the family. However, if the client adheres to the treatment regimen, her symptoms will reduce very soon because her anxiety is not very serious. Effective treatment is necessary in order to ensure that her condition does not deteriorate Practicum – Assessing Client Progress.

The items included in the privilege notes included the analysis of the contents that were discussed during the session. This means that the notes included my feeling and thoughts regarding the sessions and the client’s condition. Aspects such as the diagnosis and treatment plan are not included in the privilege notes (Brattland et al, 2018).My preceptor uses privileged notes and some of the items she includes are her analysis and hunches regarding the client’s progress. Additionally, the preceptor also includes some of the client’s private conversations that do not have to be included within the progress notes Practicum – Assessing Client Progress.