Comprehensive Client Family Assessment and Genogram The client is a 24-year-old female, single, African America active duty, service member (SM). SM who resides in the barracks medication, SM MOS is 25U, signal support specialist (IT), SM recently completed basic training and Advanced Individual Training (AIT), before enlisting SM worked as Computer Specialist. Presenting Problem: I do not know why I am here; I do not need to be here.” History of Present illness: She appears slightly disheveled, tired, and generally irritable both in the lobby, with nursing staff, and once in the room. She is accompanied by an escort who remains throughout the visit. Past Psychiatric history: Insomnia. Medical History: None Substance use History: denies Developmental History: She who appears older than stated age, the client is disheveled, with noted body odor Family Psychiatric history: no familial history Maternal grandmother marijuana user, paternal grandmother incarcerated no further history. Father Diabetes, Mother HTN, one sister HTN, 1 Brother HTN Psychosocial History: She states she was homeless before joining the Army National Guard, difficulty to find a job. She wants to go to college for nursing or IT. History of abuse/Trauma: She reports two episodes of sexual harassment in 2012 in 2013 with no sexual assault but declines to provide more information: no article 15s or negative counseling statements related to her behavior. Review of Systems: General: She is alert and oriented x 1 self only B/P 100/60 59, 24, 97.7, 99% room air. Pain 0/10, Weight 153. HEENT: no discharge intact, moist Skin: warm and dry Cardiovascular: no palpitations Respiratory: no cough or rales or expiratory wheezing was noted neither was any adventitious sounds heard. GI: No nausea, no vomiting, and no abdominal pain.. Genitourinary: She denies any burning upon urination and dribbling. No obstetrics or gynecology symptoms LMP states 05/01/2019 Neurological: She denies headaches, dizziness, and tingling in all her extremities. Musculoskeletal: FULL ROM to all extremities Psychiatric: Allergies: No known medication/ food allergies Mental Status Examination Orientation: Alert and oriented to person Appearance: in uniform, disheveled, mild body odor Musculoskeletal: gait and station intact Behavioral: Irritable/cooperative Motor activity: appropriate Speech: pressured, frenzied Mood: euthymic Affect: Irritated Restless Thought content: No suicidal ideation, no homicidal ideation Perceptions: denies auditory/visual hallucination exaggerated sense of self Thought Process: illogical and irrational Attention and Concentration: distracted Remote and Recent Memory: able to recall the last 5 minutes Judgment: delayed Insight and Judgment: fragmented Differential Diagnosis: Schizophrenia: a brain disorder that affects how a person reason, feel, and perceive. The hallmark symptom of schizophrenia is psychosis, such as experiencing ...

1. Comprehensive Client Family Assessment and Genogram
The client is a 24-year-old female, single, African America
active duty, service member (SM). SM who resides in the
barracks medication, SM MOS is 25U, signal support specialist
(IT), SM recently completed basic training and Advanced
Individual Training (AIT), before enlisting SM worked as
Computer Specialist.
Presenting Problem: I do not know why I am here; I do not need
to be here.”
History of Present illness: She appears slightly disheveled,
tired, and generally irritable both in the lobby, with nursing
staff, and once in the room. She is accompanied by an escort
who remains throughout the visit.
Past Psychiatric history: Insomnia.
Medical History: None
Substance use History: denies
Developmental History: She who appears older than stated age,
the client is disheveled, with noted body odor
Family Psychiatric history: no familial history
Maternal grandmother marijuana user, paternal grandmother
incarcerated no further history. Father Diabetes, Mother HTN,
one sister HTN, 1 Brother HTN
Psychosocial History: She states she was homeless before
joining the Army National Guard, difficulty to find a job. She

2. wants to go to college for nursing or IT.
History of abuse/Trauma: She reports two episodes of sexual
harassment in 2012 in 2013 with no sexual assault but declines
to provide more information: no article 15s or negative
counseling statements related to her behavior.
Review of Systems:
General: She is alert and oriented x 1 self only B/P 100/60 59,
24, 97.7, 99% room air. Pain 0/10, Weight 153.
HEENT: no discharge intact, moist
Skin: warm and dry
Cardiovascular: no palpitations
Respiratory: no cough or rales or expiratory wheezing was
noted neither was any adventitious sounds heard.
GI: No nausea, no vomiting, and no abdominal pain..
Genitourinary: She denies any burning upon urination and
dribbling. No obstetrics or gynecology symptoms LMP states
05/01/2019
Neurological: She denies headaches, dizziness, and tingling in
all her extremities.
Musculoskeletal: FULL ROM to all extremities
Psychiatric:
Allergies: No known medication/ food allergies

3. Mental Status Examination
Orientation: Alert and oriented to person
Appearance: in uniform, disheveled, mild body odor
Musculoskeletal: gait and station intact
Behavioral: Irritable/cooperative
Motor activity: appropriate
Speech: pressured, frenzied
Mood: euthymic
Affect: Irritated Restless
Thought content: No suicidal ideation, no homicidal ideation
Perceptions: denies auditory/visual hallucination exaggerated
sense of self
Thought Process: illogical and irrational
Attention and Concentration: distracted
Remote and Recent Memory: able to recall the last 5 minutes
Judgment: delayed
Insight and Judgment: fragmented
Differential Diagnosis:
Schizophrenia: a brain disorder that affects how a person

4. reason, feel, and perceive. The hallmark symptom of
schizophrenia is psychosis, such as experiencing auditory
hallucinations (voices) and delusions (fixed false beliefs).
Positive symptoms such as hallucinations auditory; delusions;
disorganized speech and behavior. A visible alteration in
behavior and a decrease in academic, social, and interpersonal
functioning often occurring during middle-to-late puberty.
Usually, 1–2 years pass between the onset of these vague
symptoms and the initial visit to a mental health provider
(Bertolucci, et al 2018). The first psychotic occurrence occurs
between the late teenage years and the mid-twenties. Negative
symptoms, include a decrease in emotional range, poverty of
speech, and loss of interests and ambition; Cognitive symptoms,
include neurocognitive deficits (i.e., deficits, with working
memory and attention on executive functions, in the inability to
organize thoughts; clients also find it problematic to recognize
distinctions and restraints of interpersonal signals within
relationships. Mood symptoms, clients, often seem cheerful or
sad in a way that is difficult to understand;
Bipolar Disorder: is characterized by periods of deep,
prolonged, and profound depression that alternate with periods
of an excessively elevated or irritable mood known as mania.
Manic episodes are a feature at least one week of profound
mood disturbance, characterized by elation, irritability, or
prickly (Grande et al, 2016). One of these three symptoms may
exhibit or overlap grandiosity, insomnia, excessive talking or
pressured speech; a flight of idea; distracted; excessive
pleasurable activities, often with painful consequences
Delusional Disorder; characterized by at least one month of
delusions but no other psychotic symptoms, according to the
American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders, (APA, 2013). Delusions are
categorized as persecutory (i.e., belief that one is going to be
harmed by an individual, organization or group), referential

5. (i.e., belief that gestures, comments, or environmental cues are
directed at oneself), grandiose (i.e., belief that the individual
has exceptional abilities, wealth, or fame), erotomanic (i.e., a
false belief that another individual is in love with him/her),
nihilistic (i.e., a conviction that a major catastrophe will occur),
or somatic (i.e., beliefs focused on bodily function or
sensation). Because cognitive organization and reality resting
are otherwise intact in delusional disorder, it has been defined
in the research as "partial psychosis” (Skelton,et al 2015).
Case Formulation: Reported by external sources client began
having delusional behavior, accusing the president of conspiring
against her. Client stopped coming to the formation and worked
reporting; the MP’s were poisoning her food. SM was tested for
illegal substances and alcohol (harmful) and place in Embedded
Health Inpatient for further monitoring and medication regimen
modification.
Treatment Plan: The objective to establish trust and encourage
her to take medication to decrease the symptoms.
Schizophrenia
Treatment plan: Continue to see a LCSW or psychotherapist to
assist in resurfacing symptoms and medication management.
References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington,
DC: Author.
Bertolucci, B., Pitta, J. C., Higuchi, C., Noto, C., Rocha, D.,
Joyce, D., ... & Gadelha, A. (2018). S129. Does Treatment
Resistant Schizophrenia Present A Characteristic Symptomatic
Signature?. Schizophrenia Bulletin, 44(suppl_1), S375-S376.
Detweiler, M. B., Chudhary, A. S., & Murphy, P. F. (2017).
Screening for Schizophrenia in Recruits, Active Duty Soldiers

6. and Veterans: Can we do a Better Job?. Neuropsychiatry, 7(5),
576-585.
Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar
disorder. The Lancet, 387(10027), 1561-1572.
Howes, O. D., McCutcheon, R., Agid, O., De Bartolomeis, A.,
Van Beveren, N. J., Birnbaum, M. L., ... & Castle, D. J. (2016).
Treatment-resistant schizophrenia: treatment response and
resistance in psychosis (TRRIP) working group consensus
guidelines on diagnosis and terminology. American Journal of
Psychiatry, 174(3), 216-229.
Jauhar, S., Laws, K. R., & McKenna, P. J. (2019). CBT for
schizophrenia: a critical viewpoint. Psychological medicine, 1-
4.
Jennings, K. S., Zinzow, H. M., Britt, T. W., Cheung, J. H., &
Pury, C. L. (2016). Correlates and reasons for mental health
treatment dropout among active duty soldiers. Psychological
services, 13(4), 356.
Skelton, M., Khokhar, W. A., & Thacker, S. P. (2015).
Treatments for delusional disorder. Cochrane Database of
Systematic Reviews, (5).
Brother
HTN

7. Sister
HTN
Maternal Grandfather
Deceased
Deceased
D

8. Paternal
Deceased
Maternal
Grandmother
TMarijuana User
Paternal
Grandfather
Incarcerated
‘
Client

9. Schizophrenia
Client’s Mother
HTN
Father
DIabetes
2