Assessment and Report Writing in Counselling
Student’s Name
Institutional Affiliation
Course Code and Number
Instructor’s Name
Date
Part A: Case Notes
Brian Fernandez Bruno, a 35-year-old accountant at Apple Company Limited based in California in the United States, and a devoted Catholic Christian, lives with his retired parents in the United States. Brian was referred to KillMall Medical Centre by his family doctor with a persistent one- month history of fatigue and headache symptoms after a divorce with his wife. Brian was requested by doctor to have a CT scan which showed that there existed a tumour in the left frontal lobe. After the CT results, Brian’s health worsened, and he experienced symptoms of anxiety and depression. Currently, he is in the KillMall’s medical ward awaiting results of a cranial biopsy. Besides, Brian’s critical situation follows closely his daughter’s suicidal thought early April this year.
Presenting Problems
The patient is currently suffering from one-month severe headache and fatigue tied to anxiety and depression symptoms. The patient suffers from a tumour on the left frontal lobe and is in the healthcare awaiting for his results on the cranial biopsy. The critical situation results from his earlier divorce with his fiancée, who was a co-worker in the company. The dangerous situation also led to the death of his eldest daughter aged 12 years earlier this year in April. Further, besides the leave he was given in the company, recently he has been sucked, and his contract as an accountant in the company has been terminated pushing him to street life with no single penny in his pockets.
Moreover, he has been depressed and feels lonely when he is out of the home. Brian is unable to cope with anything that comes across in his life, and he finds everything extraordinary, and he has cut off his social –relation ties with his friends. Brian’s irritability trait cannot be left out. Recently, Brian has become an alcohol addict who becomes rude when drunk and causes chaos in the society. Every day he spends the whole day in clubs drinking bottles of wine, and he argues that he does so to have peace of mind and to get out of depression.
History of Problems.
The family doctor referred Brian to KillMall Medical facility after he experienced one month fatigue and severe headache that did not even cool down after he met ophthalmologist in the medical facility. The severe headache was accompanied by insomnia, tiredness, fatigue, weakness and restlessness all over the day. The persistent headache and anxiety forced Brian to become more worried and depressed. Besides, the critical situation made him lose appetite that resulted in the loss of weight. In three weeks he lost three kilograms and faced sleep disturbances all over the night. Brian requested leave from work to regain energy and recovery as he thought that the work also gave him stress, but that was not the case. The ophthalmologist advised Brian to go for a CT scan after the symptoms persisted, and the results showed the presence of a tumour in the left frontal lobe. The worsening of his health accompanied this, and he was admitted in the hospital for biopsy of the tumour.
After the diagnosis of the tumour in the left frontal lobe, thoughts have filled his mind about his tomorrow’s life and the future of his only son aged five years old. He is experiencing sleepless and restlessness days. His parents are now taking care of his young son. Brian has become aggressive and irritable a factor that is worrying about his family members. Brian admits that he is depressed and has no energy to take care of his family. Further, he has confessed that his mind is occupied with thoughts of how he is going to recover from the anxiety and depression symptoms. To sum up, the worsening of his health conditions is due to depression and anxiety of his future life.
Relevant Personal and Family History.
Brian is a holder of Master’s degree in finance at Oxford University, and he pursued his bachelor degree in economics and Accounting at Harvard University. Brian was married to one lady before they divorced, and he is the father of one daughter and one son. Moreover, he has working experience of 25 years plus in the field of accounting and finance. Brian is son to Bruno and Carol who are both retired teachers in high schools. Besides, he is the eldest in their family of four brothers and two sisters. Brian is born in a middle-class family in the status quo, and he is the only educated child in their family. In the family, the only suicidal attempt evidenced was through a late daughter earlier this year in April. Two of his brothers are drug addicts, and recently, one of his brothers was taken to a rehabilitation Centre. The divorce cases in their family are rampant as all his brothers have divorced their first wives.
Social and Occupational factors.
Brian is a senior accountant in the Apple Company. He has served in the company for five years. Brian is well known for his competency in the finance and accounting field. Also, he has been a captain in his football club for five years.
Client Goals for Counselling
Brian has confessed that he is currently facing depression and anxiety. The symptoms were evidenced after he separated from his wife. The divorce with his wife was a shock, and this has been depressing him over the last month. The diagnosis of a tumour in the left frontal lobe has contributed to the worsening of his health conditions. Brian sought counselling from a psychiatrist on how to cope with the current situation that has left him admitted in the hospital for the last month. The primary aim of the counselling is to do away with depression and anxiety. Secondly, it is for Brian to accept that he is suffering from tumour and learn new ways of managing it with the hope of regaining energy. Thirdly, the counselling is to help him come out of drug abuse and accept that now he is single. The advice will help him know how to take care of his son and seek for Job after recovering.
Summary/Outcome of Session
The good starting point is that he has already accepted that he is facing depression and anxiety challenges, and he is willing to overcome this through counselling. The anticipated results are that he will go back to his good life, and he will cope with the current critical situation.
Part B: The Mental Status Examination.
Appearance
Brian is a 35 year –old divorced American tall man with an average weight. During the interview process, he was casually dressed in a blue shirt, jeans and black rubber shoes. Brian maintained an upright posture during the interview, and he was also cooperative. The guy was not restricted to be on the bed and appearance there were no signs of anxiety, depression and abnormal movements till when started the marital life and his working life. Suddenly, he looked depressed.
Behaviour
Brian was engaging and free throughout the interview and maintained eye contact most of the times. Further, he was calm until we stated the stories of his previous marriage and the death of her daughter. Brian changed and became aggressive and restlessness throughout the interview. Facial expressions would show when he was happy and when he was depressed.
Attitude
Brian had the right attitude towards the examiner throughout the interview, and he was averagely open and attentive during the session.
Affect and Mood
Brian’s mood was anxious and depressed. Her range of mood reduced throughout the interview. He also appeared to be irritable and angry when we talked about his previous marriage. Brian’s effect was dysphoric and euphoric. His affect was also labile and restricted.
Speech
Brian expressed himself fluently and clearly throughout the interview, however at soft, slow rate and speed. He also spoke loudly and pressured when we talked of his previous married life. The tone of the speech was shaky, and the quantity of speech was minimal.
Thoughts
The interviewer did not detect any formal thought disorder throughout the interview. Brian’s speech was minimal and answered questions clearly and spontaneously. Brian did not show any symptom of suicidal ideation. During the meeting, he was obsessed with knowing the results of biopsy whether they were right, and he kept repeating the question. Further, symptoms of phobias, compulsions and delusions were also not detected. However, he looked anxious and depressed.
Perception Disturbances
Brian showed normal perception. Grandiose, illusions, delusions and misinterpretations symptoms were also not detected.
Orientation
Confusion and disorientation symptoms were not detected as Brian answered the questions during the interview.
Consciousness
Brian did not lose memory, and he was aware of what was happening during the interview and in his previous life. He was highly conscious.
Memory
Brian’s long and short –term memory was okay, and no organic brain dysfunction was detected. He was both aware of the past and current events.
Insight and Judgement
Brian showed insight and judgement about his illness and accepted to be helped by both the doctors and nurses. He has cooperated with the doctors, and he will have medical treatment.
Part C: 7Ps Formulation
Presentation
Brian is has separated from his first wife. Affection for her wife has made him suffer from depression and anxiety. Recently, he has become a drug addict and developed a tumour in the left frontal lobe. Currently, Brian is admitted to the hospital, and he is worried about his life. Further, he seeks advice from psychiatrist oh how to overcome depression.
Pattern
Brian is having restlessness and depression symptoms for the last one month after the divorce. The tumour is tied to depression and anxiety feelings. The illness is worsening every day, and he is currently admitted in the hospital.
Predisposing factors.
Brian has high hypercholesterolemia. The biological factor and depression factors expose him to high chances of developing a brain tumour.
Precipitating Factors
Most likely, divorce has directly contributed to Brian’s brain tumour. The separation has made Brian become a drug addict, a negative factor that rampant in their family. The illness has occurred at the wrong time when he is struggling to take care of his family. Brian has also lost Job, and this is contributing to depression and anxiety.
Perpetuating Factors
Brian has lost hope of surviving after a persistent headache that has been followed by a tumour on the left frontal lobe. Brian is weak to cope with the current situations, and this has resulted in his depression and anxiety. Brian’s soft personality is, therefore, the significant factor contributing to his worsening health condition.
Prognosis
Given the weak personality of Brian, there are few chances of him recovering from the tumour, which might be cancer. Through guidance and counselling, he can recover from depression.
Potential Resources and Protective Factors.
First, Brian’s understanding of the problem will enable him to overcome depression and anxiety. Secondly, he should accept that the divorce happened and that he has developed a tumour that he might never get cure. The acceptance will enable him to cope with the situation and recover from the illness faster. Lastly, proper medication is a crucial factor for increasing his chances of recovering from the disease.
Part D: Treatment Plan template
The patient is suffering from a tumour on the left frontal lobe and depression. The client has accepted that he is suffering from depression and tumour on the left frontal lobe. Acceptance is a boost in the fight against the illness. The patient is also a devoted Christian, and prayers will play a critical role in overcoming the illness. The patient’s openness to doctors and nurses is an essential tool in the fight against the disease.
Treatment Plan
The client is suffering from depression, anxiety and tumour. The most contributing factor to the problem is the weak personality that makes him unable to cope with the current situation. The client drug abuse as a solution to
the current situation was a wrong decision. The client goal is to recover from the depression, anxiety and tumour illness and go back to his healthy life to take care of his son. To ensure that the client recovers from the disease, first, I will take him through various stages of guidance and counselling. Secondly, I will refer him to a neurosurgeon in the hospital for tumour medication. The advice and counselling will be a vital tool in making him understand and accept to cope with the current situation. The counselling will create hope of surviving and motivate him to seek medication in the hospital. The referral to the allied health practitioner will give him the best medicines for tumour. Lastly, I will refer him to a financial consultant to advise him on how he can be finically stable again after recovering. The extensive consultations with the professionals in the different sectors will play a significant role in the quick recovering of the client.
Reference
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.