Mental health comprehensive assessment

please this is my last chance to resubmit this assignment. please pay attention to the comment below

——this assignment is a Mental health comprehensive assessment

—–your HPI needs more comprehensive information.

—– I should be able to understand the differential diagnosis from your HPI.

(please explain the differential diagnoses)

—–Needs more information in the MSE section

——please complete the genogram part 2

——at least 5 references list need not more than 5 years

——Zero plagiarism

The Assignment

Part 1: Comprehensive Client Family Assessment

With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations):

  • Demographic information
  • Presenting problem
  • History or present illness
  • Past psychiatric history
  • Medical history
  • Substance use history
  • Developmental history
  • Family psychiatric history
  • Psychosocial history
  • History of abuse/trauma
  • Review of systems
  • Physical assessment
  • Mental status exam
  • Differential diagnosis
  • Case formulation
  • Treatment plan

Part 2: Family Genogram

Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

 

Learning Resources

Required Readings

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

————use scenerio below

 

HPI:Patient  is a 30 year old  female, seen via telehealth, patient gave verbal consent for treatment, patient report  she suffers alot of anxiety  and suffers from eating disorder, patient reported she use to be a model  and she was being critized about her bad and that resulted to her eating disorder, she began binge eating sometimes she goes for days without food so once she eats she will binge , patient report her weight  freaks her out, patient report gaining wieght freeks her out.Patient report she skip eating and she is very picky to maintained her weight.patient report she is currently  119 Ibs and her goal  weight is one 118 pound. Patient reprot she suffers alot of anxiety , and her mother recently passed away and it has been hard for her to accept that her mother isno more, patient report when she experience death in the family, it stop her from eating , patient report  she has not  been sleeping well , patient report being depressed , feeling down, social isolates .patient report social anxiety disorder .Patient reported  she is thinking of chnaging her names, she does not react very well to death, and she does not feel connected to her name .Patient denies any suicidal or homicidal ideation, plan or intent, denied visual of auditory hallucination.  Denies somatic complaints (headache, fatigue, stomachache, etc.)

Past Psychiatric History:

Past Diagnosis:    eating , disorder, anxiety and depression

Hospitalizations:   hospitalized a year ago for depression and eating disorder

History of suicides:  none

History of Violence:  No

History of self-mutilation: no

Outpatient Rx with a Psychiatrist: patient was receiving treatment from a psychiatrist  Nurse practitioner

Psychotherapy: currently  at  Pathways in Hollywood

Medications trials in the past:lexapro ,lovox,

Current psychotropics: mirtazapine, klonopin ,prochlorperazine

Medication History:

 

Date

Medication

Sig

#

Refill

Status

 

06/25/2020

Zoloft 25 mg tablet

1 tablet by mouth daily

30

0

Active

 

06/25/2020

Remeron   15 mg tablet

1   tablet by mouth nightly

30

0

Active

 

06/25/2020

prochlorperazine maleate 10 mg   tablet

1 tablet by mouth daily

0

Active

Allergies:

patient reproted she is allergic  to red colour  food or pills

Social History:

Social: Patient is single , no kids

Develpmental: born and raised  in Maryland

Alcohol: drinks occassionally

Drug: ; Denies

Abuse: denies

Faith: christian

Occupation: unemployed

Education: High school diploma

Legal: Denies

Family History:

patient denies any family history of mental or medical problems

Review of Systems:

Constitutional

Denied:

Chills. Decline in Health. Fatigue. Fever. Malaise. Other abnormal constitutional symptoms. Weakness. Weight Gain. Weight loss.

Eyes

Denied:

Blurry Vision. Cataracts. Discharge. Double Vision. Excessive tearing. Eye Pain. Eyeglass Use. Glaucoma. Infections. Pain with Light. Recent Injury. Redness. Unusual sensations. Vision Loss.

Respiratory

Denied:

Asthma. Bronchitis. Cough. Coughing Blood. Pain. Pleurisy. Positive TB Test. Recent Chest X-Ray. Short of Breath. Sputum. Tuberculosis. Wheezing.

Cardiovascular

Denied:

Chest Pain. Extremity(s) Cool. Extremity(s) Discolored. Hair loss on legs. Heart murmur. Heart Tests (Not EKG). High blood pressure. history of heart attack. Leg Pain – Walking. Palpitations. Recent Electrocardiogram. Rheumatic fever. Short of Breath – Exertion. Short of Breath – Lying Flat. Short of Breath – Sleeping. Swelling of legs. Thrombophlebitis. ulcers on legs. Varicose veins.

Gastrointestinal

Denied:

Abdominal Pain. Abdominal X-Ray Tests. Antacid Use. Black Tarry Stools. Change in Frequency of BM. Change in stool caliber. Change in stool color. Change in stool consistency. Constipation. Decreased Appetite. Diarrhea. Excessive Hunger. Excessive Thirst. Gallbladder Disease. Heartburn. Hemorrhoids. Hepatitis. Infections. Jaundice. Laxative Use. Liver Disease. Nausea. Rectal Bleeding. Rectal Pain. Swallowing Problem. Vomiting. Vomiting Blood.

Musculoskeletal

Reported:

joint problems. 

Denied:

disturbances of gait or station. muscle strength. tone.

Psychiatric

Reported:

Depression. Nervousness. Mood changes. 

Denied:

Behavioral Change. compulsive. delusions. depressive symptoms. Disorientation. Disturbing thoughts. Excessive stress. Hallucinations. intrusive. manic symptoms. Memory loss. persistent thoughts. Psychiatric disorders. ritualistic acts. suicidal ideas or intentions.

Skin

Reported:

Easting disorder ,scolliosis , seizures  

Denied:

Dryness. Eczema. Hair dye. Hair texture change. Hives. Itching. Lumps. Mole Increased Size. nail appearance change. nail texture change. Rashes. Skin Color Change.

Neurological

Reported:

seizures disorder  

Denied:

Blackouts. Burning. Dizziness. Fainting. Head Injury. Headaches. Loss of consciousness. Memory loss. Numbness. Paralysis. Speech disorders. Strokes. Tingling. Tremors. Unsteady gait.

Endocrine

Denied:

Cold intolerance. Excessive Urination. Fatigue. Goiter. Heat intolerance. Increased Thirst. Neck Pain. Sweats. Thyroid Trouble. Weakness. Weight gain. Weight loss.

Hematologic/Lymph

Denied:

Anemia. Bleeding easily. Blood clots. Easy bruisability. Lumps. Radiation Exposure. Swollen glands. Transfusion reaction.

Allergic/Immunologic

Denied:

Coughing. Coughing with Exercise. Hives. Itchy Eyes. Itchy Nose. Recurrent infections. Runny Nose. Sneezing. Stuffy Nose. Watery Eyes. Wheezing. Wheezing with exercise.

Genitourinary

Urinary

Denied:

Awakening to Urinate. Bed-Wetting. Blood in Urine. Burning. Difficulty Starting Stream. Excessive Urination. Flank Pain. Frequency. Incontinence. Infections. Pain on Urination. Retention. Stones. Urgency. Urine Discoloration. Urine Odor.

Female Genitalia

Reported:

Menopause. 

Denied:

Birth control. Bleeding Between Periods. Change in Periods – Duration. Change in Periods – Flow. Change in Periods – Interval. DES Exposure. Difficult Pregnancy. Discharge. Fertility problems. Hernias. Itching. Lesions. Menstrual pain. Pain on Intercourse. Postmenopausal Bleeding. Recent Pap Smear. Recent Pregnancy. Sexual Problems. Venereal Disease.

Objective

Vital Signs:

Height, Weight, BMI and Measurements

 

Height

Weight

BMI

Flag

Head

Neck

Waist

 

5′ 11″

119 (lb)

16.6

Underweight

Physical Exam:

Constitutional

The patient is awake, alert, well developed, well nourished and well groomed.

Age Sex Race:

The patient is a 30 years old female who appears the stated age. 

Distress:

This patient is in no acute distress.

Apparent State of Health:

This patient appears to be in generally good health.

Level of Consciousness:

The patient is awake, alert, understands questions and responds appropriately and quickly.

Nutrition:

The patient is well developed and well nourished.

Grooming:

The patient’s is clothing clean and properly fastened. The patient’s hair, nails, teeth and skin are clean and well groomed.

Odor:

The patient’s breath and body odor are normal.

Deformity:

There are no obvious deformities

Psychiatric

Orientation

The patient is oriented to time, place and person.

Memory

Testing for the accuracy of remote and recent memory is within normal limits.

Attention

Attention testing for digit span and serial 7s is within normal limits.

Language

Aphasia evaluation including testing for word comprehension, repetition, naming, reading comprehension and writing were performed and are normal.

Knowledge

The patient’s fund of knowledge: awareness of current events and past history is appropriate for age.

Mood Personality

The patient’s mood is described as sadness The affect is appropriate The patient has the following symptoms of a depressed mood: depressed or irritable mood most of the day nearly every day, fatigue or loss of energy nearly every day, feelings of worthlessness or inappropriate guilt nearly every day, markedly diminished interest or pleasure in almost all activities most of the day nearly every day, insomnia or hypersomnia nearly every day The mood disorder is consistent with major depressive episode  

The patient’s social skills are appropriate. The patient does not exhibit any traits consistent with personality disorder.

Speech

The speech rate and quantity is normal and the volume is well modulated. The patient is articulate, coherent; and spontaneous. The flow of words is consistent with normal fluent speech.

Thought Processes

The patient’s thought processes are logical, relevant, organized and coherent.

Associations

The patient’s associations are intact.

Thought Content

There are no obsessive, compulsive, phobic, delusional thoughts. There are no illusions or hallucinations.

Judgment

The patients judgment concerning everyday activities and social situations is good and insight into their condition is appropriate.

MSE : Exam – Mental Status

Appearance

Patient appears to be calm., Patient appears to be friendly., Patient appears to be happy., The patient looks relaxed..

Memory

The patient seems to have immediate memory..

Speech Quality

The patient seems to have normal speech..

Language

The patient expressive language is good.. The patient displays good comprehension language..

Motor Activity

The patients motor activity seems to be normal..

Interpersonal

The patient seems to be friendly..

Behavior

The patients behavior is cooperative..

Stated Mood

The patient seems to be in a okay mood..

Affect

The patient present normal affect..

Psychosis

The patient seems not to be psychotic..

Suicidal

The patient convincingly denies suicidal ideas or intentions..

Homicidal

The patient convincingly denies homicidal ideas or intentions..

I.Q.

Vocabulary and fund of knowledge indicate cognitive functioning in the normal range..

Judgment

Judgement appears intact.

Attention

There are no signs of hyperactive or attention difficulties..

Assessment

Diagnosis:

 

Comment

 

Major Depressv Disorder, Recurrent   Severe W/o Psych Features

 

Other   Specified Anxiety Disorders

 

Generalized Anxiety Disorder

 

Binge   Eating Disorder

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