Unit 10 Assignment Final Treatment plan.pdf - CASE STUDY...

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CASE STUDY TREATMENT PLAN BIOPSYCHOSOCIAL ASSESSMENT FORM Cultural Background: Name: Rosalyn Age: 59 Gender: female Race: Rosalyn is identifies as being Black Ethnicity: Rosalyn is an African American Religious Issues: Christian Baptist, Rosalyn reports that she is a member of her church however, she does attend church weekly but states she attends maybe one or twice a month. Sexual Orientation: Rosalyn identifies as being a heterosexual Relevant Cultural Norms: Relevant cultural norms are, Rosalyn is a 59 year old widow who was married for 31 years until he passed away from a massive heart attack and now four years later she is questioning her understanding about starting a new relationship, she wants to make sense of her sexual desires. Other Relevant Cultural Norms: Other relevant cultural norms are, Rosalyn being concerned and needing some helpful direction in moving forward in a relationship at her age and after being married for 31 years to
a man that took care of her and a relationship she had been happy in for so long, and now to be sexually attracted to another man and wanting him to meet her expectations. Current Symptoms: Reason for Visit Listed as DSM-5 Symptoms: Unspecified Sexual Disorder 302.70 (F52.9), Rosalyn does not fit in any of the categories for sexual dysfunctions, however, Rosalyn felt discomfort due to vaginal dryness (may be due to menopause but not enough information yet). Rosalyn is still trying to get used to not having her husband and states that she feels a combination of emotions after having a sexual encounter after 4 dates with Matthew. Rosalyn was not satisfied sexually with Mathew as she was with her husband Adjustment disorder diagnostic criteria A with anxiety 309.24 (F43.22) Rosalyn could be in need of counseling attention to have some focus directed to toward Relationship Distress With Spouse or Intimate Partner code # V61.10 (Z63.0), the sexual encounter was not what Rosalyn anticipated. Rosalyn stated that she experienced pain during intercourse due to vaginal dryness and Mathew was not in tuned to her sexual needs only his needs seemed to matter. Rosalyn could be in need of counseling attention due to the death of her husband of 31 years which would be in the DSM-5 category of Uncomplicated bereavement code # V62.82 (Z63.4)   Family Background: Family of Origin Issues: Rosalyn lost her husband of 31 years from a heart attack 4 years ago. She was introduced to Matthew and is unsure whether or not to continue the relationship after having a sexual encounter and was not satisfied. Rosalyn wants to learn how to live again but questions her ability to select the right intimate partner. Family Environment in Childhood/Adolescence: Rosalyn stated that she struggled early in life to accomplish her goals and takes much pride in her efforts. Rosalyn has not yet gone into detail in regard to her child hood.

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