Assessing Clients

Presenting problem

Juan Hernandez Junior described a punishment at school that led to them calling the ACS. The school social worker was told of how the Hernandez parents made him kneel on his knees for hours while holding two heavy encyclopedias in each hand as a form of punishment. He reiterated that this punishment had been used on them on several occasions and this led to the ACS sending a worker to their home. The ACS worker thought that the concern was credible since this form of punishment was abusive and suggested that they start attending family sessions and visit the local community mental agency to complete a parenting group.

History or present illness

Past psychiatric history

Parents report that Juan Jr. has been of sound psychiatric health.

Medical history

Parents report that Juan Jr has been healthy. However, his mother has been diagnosed with diabetes recently.

Substance use history

Both parents have no history of substance abuse nor does Juan Jr.

Developmental history

Parents reports no delays.

Family psychiatric history

Parents report no psychiatric problems in their family history.

Psychosocial history

Juan Jr is quite sociable. He and his parents go to the beach and the park near their home on weekends to socialize and play.

History of abuse/trauma

Prior to the current problem that involves the form of punishment that the Hernandez are using on their children, there are no other abuse incidents that Juan Jr. has experienced.

Review of systems

Gen: Has no fever, night sweats, heat intolerance, weakness or fatigue.

Head: No migraine headaches reported.

ENT: No visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore throat, or speech difficulty

Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes.

Cardiopulmonary: Patient indicates they have not witnessed any instances of cough, dyspnea, wheezing, hemoptysis, chest pain, palpitations, orthopnea, murmurs, edema, claudication, syncope, hypertension.

GI: There have been no changes to the patients eating habits. He has tested negative for n/v, hematemesis, melena, dysphagia, heartburn, flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea, constipation, hematochezia, or rectal pain.

GU: He also has been cleared of dysuria, frequency, nocturia, hematuria, urgency incontinence or polyuria.

MS: On the other hand, he has reported no backache, joint pain, stiffness. Gait is normal and steady.

Heme/Skin: Patient insists they have had no bleeding, bruising, anemia. Denies changes, pruritis, rash, or changes in hair.

Neuro: No indication of seizures, paralysis, muscle weakness, parasthesia, sensation changes.

Psych: Thought content: no SI/HI or psychotic symptoms; Associations: intact; Orientation: x 3; Mood and affect: euthymic and full and appropriate.

Physical assessment

Vital Signs:

47 Height: inches

Weight: 129lbs

Temp: 37 0C.

RR: 16

BP: 120/59

Pulse: 79 BPM

Appearance: Slender, Latino male who appears his age and no distress observed. He is well groomed and dressed to impress.

Mental status exam

The whole family comes to the appointment since they have to do both family sessions and a positive parenting program for the parents. Juan Senior comes on with a lot of anger and resentment towards the counselor a she sees no point in attending the classes.

Differential diagnosis

The parents grew up too fast and are projecting their feelings on their children.

Diagnosis

Anger Management issues

Case formulation

The Hernandez parents, Juan Senior and Elena are brought for sessions by the ACS as a result of their son’s abuse allegations. Juan Hernandez is a 27 year old Latino man who works as a casual worker at the airport with back problems due to the amount of heavy lifting he has to do on a daily basis. He has no drug abuse problem but a criminal history of juvenile petty theft that has since been expunged. Additionally, he takes approximately six to eight beers every weekend. On the other hand, Elena is a 25 year old Latino woman born in Puerto Rico but raised in New York who was recently diagnosed with diabetes. She has no drug abuse problem nor a criminal history. She drinks 1 or 2 drinks a month.

Treatment plan

Treatment Goals

The weekly parenting classes and family sessions will teach the parents effective and safe discipline skills, the importance of recognizing age-appropriate behavior, managing one’s frustrations, and the child development techniques that boosts child’s self-esteem and their sense of confidence. It will also help the family as a whole come to terms with the situation at hand.