form of punishment that the Hernandez are using

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.

 

HERNANDEZ CASE STUDY 4

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, and 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, and 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:

HERNANDEZ CASE STUDY 5

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 should 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 should do

daily. 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.

HERNANDEZ CASE STUDY 6

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 come to terms with the situation at hand.

Estimated Completion: 3 Months

Objective #1

The parents will be able to discipline their children effectively and using safe options.

Treatment Strategy / Interventions: This will be done through teaching the parents the most effective and safe discipline skills they can use. These may include techniques such as setting

limits like taking away their privileges and using time-out. This can on

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