The document presents a comprehensive client assessment of T.C., a 73-year-old African American male experiencing increased psychosis with auditory hallucinations and self-harm tendencies. His medical history includes chronic illnesses, and he has a significant history of drug use and homelessness, complicating his mental health issues. A treatment plan with medication management and psychotherapy is suggested to address his symptoms and improve his overall well-being.

1. Running head: ASSIGNMENT 2: PRACTICUM – ASSESSING
CLIENTS 1
10
ASSIGNMENT 2: PRACTICUM – ASSESSING CLIENTS
Assignment 2: Practicum – Assessing Clients
Part 1: Comprehensive Client Family Assessment
Demographic information: T.C is a 73 years old African
American male who was admitted after being discharged from
another local hospital.
Presenting problem: The patient’s present problem is increased
psychosis with auditory hallucination (AH).
History or present illness: The patient has a history of multiple
hospitalizations, of which he refused to give further details. He
was however diagnosed with increased psychosis with auditory
hallucination and reports of being capable of hurting himself
and others. He was planning to harm himself with an ice pick on
the neck. He claims that he has been having auditory
hallucinations telling him to harm himself. He was unable to
state the onset of the symptoms of the presenting illness. He
was not cooperating with the clinician.
Past psychiatric history: The patient has a history of multiple
hospitalizations, which he refused to discuss further.
Diagnoses: Chronic mental illness
Suicidal gestures or attempts: None
Medical history: Cerebrovascular accident (CVA), Hypertension
(HTN), chronic obstructive pulmonary disease(COPD), Seizure,
Congestive heart failure (CHF).
Surgical history: None
Allergies: No known drug allergies
Current Medication:
· Aspirin oral 81 mg TC, PO daily for the management of CAD
· Rivaroxaban oral 10mg tablets PO daily for the management
of CAV/MI
Substance use history: The patient claims to be using cocaine as

2. much as he can, once a month. He claims to have started using
the drug when he was 19 years old. He, however, refused to
give the last day that he used the drug. He also smokes
marijuana once a day and started using it when he was 17 years
old. He smokes cigarettes at least 3 to 4 times a day.
Developmental history: The patient is a 73-year-old African
American male. He is homeless. He is a Christian. His past
daily activities include playing soccer and taking an active role
in community services. All his early motor, social, language in
addition to emotional milestones were within normal limits
before being diagnosed with a psychological disorder.
Family psychiatric history: Negative family psychiatric history.
There is no known history of any of the family members
suffering from any psychiatric disorder, or under psychiatric
medications or hospitalization. No other family member has
ever displayed suicidal behavior or substance abuse.
Psychosocial history: The patient has a history of chronic
mental illness and is non-compliant to medical treatment.
History of abuse/trauma: The patient has no reported history of
abuse or trauma.
Review of systems:
General: No weight change, generally appears to be confused.
He presented with poor insight and unable to respond to most
questions during an assessment. He does not exercise as much
as he used to.
Skin: He denies any changes in his
skin, pruritis, rash, or changes in hair color.
Head: The patient is positive for occasional migraine headaches.
Neck: He denies neck swelling, stiffness or pain.
ENT: Ears: No change in hearing, no tinnitus, no vertigo. Nose:
No epistaxis, no discharge. Mouth: Yellow colored teeth. No
gingival bleeding, no use of dentures. Oropharynx: no erythema
or exudates and no enlargement of tonsils.
Chest: Experiences shortness of breath sometimes with dry
cough. He denies wheezing.
Cardiovascular: Denies chest pains, palpitations, syncope or

3. orthopnea.
Abdomen: Complains of decreased appetite. Denies abdominal
pains, or bowel habit changes.
Gastrointestinal: Denies nausea, vomiting, vomiting,
regurgitation;
Genitourinary: Denies urinary urgency, dysuria, and change in
the nature of urine.
Hematologic: Denies bleeding, bruises or anemia.
Lymphatics: No history of enlarged lymph nodes or
splenomegaly
Endocrinologic: Denies changes in hair or skin color,
polydipsia, polyuria or polyphagia.
Musculoskeletal: Denies pain in muscles or joints, limitation of
range of motion, paresthesia or numbness.
Neurologic: Complains of general body weakness. Denies
tremors and ataxia. Has a history of seizures.
Psychiatric: Patient has a history of chronic mental illness. He,
however, denies hallucination, delusion, or suicidal thoughts.
He was however diagnosed with increased psychosis with
auditory hallucination and harm to self and others.
Physical assessment
Height:
Weight:
Temp:
RR:
BP:
Pulse:
Appearance: He appears poorly groomed, and unhygienic. He
seems to be very anxious and unresponsive to the questions
asked during physical examination. He is also glum and
inattentive. He is somehow sad, littles and depressed. The
slowness of his physical movement helped reveal a depressed
mood. His facial expressions also revealed a sad and depressed
mood. Generally, he looks hopeless.
Mental status exam:
· Appearance: the patient has a disheveled and unkempt

4. appearance, with poor eye contact and paranoid.
· Motor activity: the patient is restless with excessive motor
activities such as pacing, inability to sit still and wringing of
hands (Smith, Johns, & Mitchell, 2017).
· Speech: The patient is withdrawn, and talks very slowly only
when he feels like talking.
· Mood and Affect: Patient seems to be in a depressed hopeless
mood.
· Thoughts: The patient is delusional and thinks of harming
himself and others.
· Perceptual distribution: The patients complain of auditory
hallucination.
· Sensorium and cognition: The patients lose concentration
several times during physical examination (Smith, Johns, &
Mitchell, 2017).
· Insight: The patient is aware of his ills but noncompliant to
previous medication.
· Judgment: The patient is of poor judgment.
Differential diagnosis (Griswold, Del, & Berger, 2015):
· Opioid use, unspecified with opioid-induced psychotic
disorder with hallucinations (F11.951):
· Alcohol dependence with alcohol-induced psychotic disorder
with hallucinations (F10.251):
· Auditory hallucinations (R44.0):
Case formulation:
Based on the patient history, physical and mental examination
findings, the patient is most likely suffering from increased
psychosis with auditory hallucination. He reports having
auditory hallucinations telling him to harm himself and others.
He also has a history of chronic mental illness of which he was
noncompliant to medication. He is homeless and has no one to
take care of him. He has been using cocaine, marijuana, and
been cigarette smoking for several years, and does not seem to
quit. According to the Diagnostic and Statistical Manual of
Mental Health Disorders, 5th edition (DSM-5), substance-
induced psychotic disorder is diagnosed base on the presence of

5. either one or both of the following symptoms, delusion, and
hallucination, and evidence of both delusion or hallucination
immediately after substance intoxication or withdrawal or after
exposure to the drug (Munjampalli & Davis, 2016). As a result,
the patient’s mental condition might have been as a result of
drug abuse. Hence, he is most likely suffering from opioid-
induced psychosis with hallucination. However, excessive use
of alcohol can also lead to hallucination and with alcohol
dependence, the individual can develop psychosis (Sivanesan,
Gitlin, & Candiotti, 2017). Thus, alcohol dependence with
alcohol-induced psychotic disorder with hallucination is also a
possible diagnosis.
Treatment plan
In most cases, hallucinations do not necessarily need
pharmacotherapy if the experience is not intrusive and does not
interfere with others. However, in the above case study, the
patient has proven the potential of causing harm to himself and
others. As such, the best treatment of choice is the use of
antipsychotic medication. However, the clinician is expected to
discuss with the patient all the benefits and adverse effects of
each drug including the possibilities of the drugs to cause
symptoms such as metabolic and extrapyramidal syndrome
(Hayward, 2018). Consequently, the clinician is expected to
monitor the physical health of the patient on a regular basis. In
the above case scenario, T.C needs to continue using the
prescribed medications to manage his symptoms as follows:
· Mood/anxiety/sleep: Administer 200mg quetiapine oral tablets
once a day at bedtime for 6 months.
· Mood: After 4 weeks, when the patient is compliant, lower the
dose of quetiapine oral tablets to 100mg every morning for
three months.
· Insomnia: Two months later, to control insomnia, start the
patient on mirtazapine oral 15mg tablets at bedtime every night.
· Mood: two months later, the patient should reduce the dose of
quetiapine oral to 50 mg tablets, each tablet every morning.
· During the following month's visit, start the patient on

6. clonazepam oral 1 mg tablets twice per day to manage anxiety.
· If the patient's symptoms still persist, increase the dose of
quetiapine to 300 mg orally every bedtime.
Additionally, the patient should be enrolled in a psychological
treatment plan. Most studies show that some patients may be
more responsive to cognitive behavioral therapy more than
pharmacotherapy (Hayward, 2018). Psychotherapy will focus
more on evaluating and monitoring the patient's perception,
beliefs, and reasoning and promote alternative ways of coping
with the symptoms and reduce stress.
Lastly, peer support group is also necessary as it will help the
patient alleviate the impact of voice. Self-help groups help
patients take responsibility for their hallucinatory experience,
accept and cope with the voices (Slotema, Blom,
Niemantsverdriet, & Sommer, 2018). With the above
interventions, the patient's symptoms will be controlled
appropriately.
Part 2: Family Genogram for T.C
Child SN
Child PN
Child GT
Child HT
Child TL
Child BL
Child TC
Child QC
Parent ON
Parent LC
Parent HL
Parent JT

7. Great grand Parent C M
Grand Parent ML
Grand Parent NL
References
Griswold, K. S., Del, R. P. A., & Berger, R. C. (January 01,
2015). Recognition and differential diagnosis of psychosis in
primary care. American Family Physician, 91(12), 856-863.
Hayward, M. (May 01, 2018). Evidence-based psychological
approaches for auditory hallucinations: Commentary On…
Auditory Hallucinations in Schizophrenia. Bjpsych Advances,
24(3), 174-177.
Munjampalli, S. K., & Davis, D. E. (January 01, 2016).
Medicinal-Induced Behavior Disorders. Neurologic Clinics,
34(1), 133-169.
Sivanesan, E., Gitlin, M. C., & Candiotti, K. A. (January 01,
2017). Opioid-Induced Hallucinations: A Review of the
Literature, Pathophysiology, Diagnosis, and Treatment. Survey
of Anesthesiology, 61(1), 21-21.
Slotema, C. W., Blom, J. D., Niemantsverdriet, M. B. A., &
Sommer, I. E. C. (2018). Auditory Verbal Hallucinations in
Borderline Personality Disorder and the Efficacy of
Antipsychotics: A Systematic Review.
Smith, L. M., Johns, L. C., Johns, L. C., & Mitchell, R. L. C.

8. (September 01, 2017). Characterizing the experience of auditory
verbal hallucinations and accompanying delusions in individuals
with a diagnosis of bipolar disorder: A systematic review.
Bipolar Disorders, 19(6), 417-433.
Assignment 2: Practicum – Assessing Client Progress
Learning Objectives
Students will:
· Assess progress for clients receiving psychotherapy
· Differentiate progress notes from privileged notes
· Analyze preceptor’s use of privileged notes
To prepare:
· Reflect on the client you selected for the Week 3 Practicum
Assignment.
· Review the Cameron and Turtle-Song (2002) article in this
week’s Learning Resources for guidance on writing case notes
using the SOAP format.
The Assignment
Part 1: Progress Note
Using the client from your Week 3 Assignment, address the
following in a progress note (without violating HIPAA
regulations):
· Treatment modality used and efficacy of approach
· Progress and/or lack of progress toward the mutually agreed-
upon client goals (reference the Treatment plan—progress
toward goals)
· Modification(s) of the treatment plan that were made based on
progress/lack of progress
· Clinical impressions regarding diagnosis and/or symptoms
· Relevant psychosocial information or changes from original
assessment (i.e., marriage, separation/divorce, new
relationships, move to a new house/apartment, change of job,
etc.)
· Safety issues
· Clinical emergencies/actions taken
· Medications used by the patient (even if the nurse

9. psychotherapist was not the one prescribing them)
· Treatment compliance/lack of compliance
· Clinical consultations
· Collaboration with other professionals (i.e., phone
consultations with physicians, psychiatrists, marriage/family
therapists, etc.)
· Therapist’s recommendations, including whether the client
agreed to the recommendations
· Referrals made/reasons for making referrals
· Termination/issues that are relevant to the termination process
(i.e., client informed of loss of insurance or refusal of insurance
company to pay for continued sessions)
· Issues related to consent and/or informed consent for
treatment
· Information concerning child abuse, and/or elder or dependent
adult abuse, including documentation as to where the abuse was
reported
· Information reflecting the therapist’s exercise of clinical
judgment
Note: Be sure to exclude any information that should not be
found in a discoverable progress note.
Part 2: Privileged Note
Based on this week’s readings, prepare a privileged
psychotherapy note that you would use to document your
impressions of therapeutic progress/therapy sessions for your
client from the Week 3 Practicum Assignment.
· The privileged note should include items that you would not
typically include in a note as part of the clinical record.
· Explain why the items you included in the privileged note
would not be included in the client’s progress note.
· Explain whether your preceptor uses privileged notes, and if
so, describe the type of information he or she might include. If
not, explain why.