Comprehensive Client Family Assessment Demographic.docxAASTHA76
Comprehensive Client Family Assessment
Demographic information: Latino American family. Low socioeconomic status, working class.
Presenting problem: “Social worker believes our discipline style is too harsh and we need
parenting classes”
History of Present Illness: Both clients present to the office with concerns regarding their
children being “taken away” by social services as she believes they parent too harshly. They
adamantly proclaim that they are very good, loving parents but believe that when a child is not
following the rules, strict and physical discipline is necessary. They both explain that they were
brought up this way and that physical or emotional abuse is not present. They explain that this is
part of their culture and all they know is right. The social worker referred to the family as “those
Mexicans” and seemed to be bias towards the family. Also, she seemed to not consider any
alternative for the family after they requested it based on their working schedule and after
explaining their cultural belief system.
Past Psychiatric History: “Needs to be added to”
Medical History: “Needs to be added to”
Substance Abuse History: No indication for substance abuse. “Needs to be added to”
Developmental history: Parents report that their two sons all have met their milestones
throughout their development and are ages 6 and 8 years old. “Needs to be added to”
Family psychiatric history: “Needs to be added to”.
Psychosocial history: Male client works full-time and overtime to provide for the family. “Needs
to be added to”.
History of abuse/trauma: Based on the genogram created, both clients father and mother have a
history of disciplining their children similarly. They both would require the clients to hold
encyclopedias out in front of them until their arms “felt like they were going to fall off”. Both
clients report this type of discipline as being miserable and that they inherited this from their
parents. No physical or mental abuse of concern.
Review of Systems:
HEENT: No loss of vision or hearing. No sign of congestion, sore throat, or runny nose.
SKIN: Cool and dry skin with no signs of wounds or lesions.
CARDIOVASCULAR: No complaints of chest pain, tightness, discomfort or palpitations. S1,
S2 heard upon auscultation. 2+ pedal and radial pulses. No weight gain and no edema.
RESPIRATORY: Clear lung sounds with no adventitious sounds. No rhonchi or wheezes
auscultated, and chest is symmetrical. No cough present.
GASTROINTESTINAL: No nausea, emesis, or diarrhea. Abdomen soft, no distention, no
discomfort on palpation. Bowel sounds present in all four quadrants.
GENITOURINARY: No burning or discomfort when urinating.
NEUROLOGICAL: No double vision, headaches, seizures. No loss of memory. Alert and
oriented x person, place and time. Agitation present in male client.
MUSCULOSKELETAL: No joint or muscles pain. No g.
CASE STUDYFemale, 15, separation anxiety disorder, Depression.docxbartholomeocoombs
CASE STUDY:
Female, 15, separation anxiety disorder, Depression
The patient is a fifteen-year-old female teenager who presents to the clinic with her mother for her first assessment. Patient is being referral to the clinic by the school counselor due to low grades and poor school assistance. During the session, both the patient and the mother are neatly dressed. Her mother seems to be worried about her daughter. The patient said, "I worry a lot about my family members. I fear that one day my parents will be abducted or fatally injured. The worries and fears make me have difficulties concentrating on personal well-being and my studies in school." The mental assessment shows that the patient is depressed, and she refuses to leave the proximity of her mother. Her mother says that her daughter has been experiencing depression or anxiety attacks. The physical assessment shows that the patient has been experiencing physical aches and pains. She maintains good eye contact. Her mood is a little anxious. The symptoms conclude that the patient has separation anxiety disorder because the symptoms have progressed for the past six months. Treatments include antidepressants, group therapy, family therapy, dialectical behavioral therapy, and cognitive-behavioral therapy. A follow-up is to be done in two weeks.
Assignment 2: Focused SOAP Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
· Specifically address the following for the patient, using your SOAP note as a guide:
·
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
·
Objective: What observations did you make during the psychiatric assessment?
·
Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum o.
INITIAL CASE CONCEPTUALIZATION8Initial Case Conceptua.docxjaggernaoma
INITIAL CASE CONCEPTUALIZATION 8
Initial Case Conceptualization
Nichole Hairston-Purvis
Dr. Stephanie Warren
COUN6332
Capella University
February 12, 2018
PSYCHOLOGY
Part One: Client Information
This paper focuses on S. H., a client that the therapist has been speaking with in counselling sessions over a couple of weeks since they met during an internship program in the field. S.H. is 25 years of age. The client resides in Detroit City in Michigan, United States of America as a first generation immigrant, her country of origin being Nigeria in Africa. Having migrated into the U.S with her parents, 2 brothers and a sister when she was 11 years old, she is an African American citizen. She speaks both fluent English and Spanish. The client is a staunch Muslim and her wealthy parents live in New Jersey, U.S. S.H. has been working as a credit officer at a locally based bank until she was dimissed a few months ago .She rarely asks for financial support from her parents despite the fact that she is out of job.
The client does not portray any signs of physical disability and appears physically healthy. S.H. did not complete her college education after she got pregnant, arguing that she could not properly manage college, full time job and raising a baby. S.H.’s siblings are graduates having professional careers. The client has a son who is 2 years old and she claims that sometimes she feels ‘overwhelmed’ because of raising him all alone as her husband serves in the military and has been away for nine months. Client reveals that it has now been two years since she saw her family. Furthermore, she states that her relationship with her parents is ‘close’ despite mentioning that her father is an excessive drinker. Her father and mother are a banker and an educator respectively.
While presenting her concerns and problems the client said, “I lost my job a few months ago which has brought a feeling of hopelessness. I am having sleepless nights and I have lost my appetite.” Over the past two months, the client reported having lost eight pounds. Despite worrying about being a solo parent, she also fears that she might become homeless. S.H stated, “I am always worried. I am completely stressed out. My husband has been away for nine months serving in the military .I am always worried about him.” During her various appointments, S.H. has been arriving thirty minutes earlier. She also reported that she had never attended any counselling in the past. The client appeared to be suffering from depression and anxiety due to the fact that the client presented with shaky hands and was tearful during while completing her intake paperwork. During the description of her problems and her decision to seek out therapy, she made limited eye contact .She had a halting speech. The client seemed pretty willing and commitment to the nine treatment sessions recommended by her insurance company.
Part 2: Theoretical Framework
.
Informatics meshes technology and information into something usefu.docxannettsparrow
Informatics meshes technology and information into something useful. In nursing, informatics uses media such as health portals, mobile apps, social networking, and telehealth to aide nurses, patients and other stakeholders in decision making. When utilizing informatics our knowledge increases, we communicate better, we become more efficient with our job, and we provide better patient care.
As a hospice nurse, I often admit patients with very little to no medical history. My scenario would be to have a database that shares all health information for patients. If this would be available, decisions could be made that is in the best interest of the patient immediately and not have to wait for information to be sent. When having to wait, it impedes patient care and often has to backtrack and change the plan of care. Many times there is vital medical history missed because the patient/family member is a poor historian due to disease process or stress of the situation. If there is one database for all information potential medication errors could be avoided because you would know information such as allergies, current and previous medications prescribed.
This technology is already available to some extent in the prescription pain medicine world. The prescription drug monitoring program (PDMP) is a database that keeps track of controlled substances being prescribed. This is used in the fight against the opioid epidemic occurring today.
This idea is not new but has not come to fruition yet. If this was to occur, HIPPA would have to be strictly maintained. This could happen by having the patient sign an agreement allowing their information to be in the database and every provider having access to it. Many people travel even state to state and if there was a national database, all health records would be available at the fingertips of the provider no matter where the patient was allowing efficient and knowledgeable patient care.
Laureate Education (Producer). (2018). What is Informatics? [Video file]. Baltimore, MD: Author.
Laureate Education (Producer). (2018). Health Informatics and Population Health: Trends in Population Health [Video file]. Baltimore, MD: Author.
Discussion Topics, Mohr
Chapter 6, Culture
Discussion Topics
Learning Objective
1. During her first semester of nursing school, Felecia was assigned to a patient belonging to the American Indian culture. Felicia began to compare her own cultural beliefs with that of her patient.
a. To what ethnic, socioeconomic class, and community do you feel a part of or belong?
b. What are the values of your cultural group?
c. What are your attitudes toward people who are different from you in appearance or behavior?
1, 2, 10
2. When caring for an individual who belongs to a different culture, there may be variations in health concept and promotion.
a. List a cultural group, what their concept of health may be, and discuss variations as well as potential health promotion beliefs.
6
3. Maria is a .
Final Test and AssessmentNameUniversityDat.docxAKHIL969626
Final Test and Assessment
Name
University
Date
Running Head: FINAL TEST AND ASSESSMENT 1
FINAL TEST AND ASSESSMENT 6
Client: Barbara B.
Date of birth: 2/20/1993
Evaluated by:
Case No.: 1234
Date of Evaluation: 3/25/15
Date of Report: 2/25/18
PURPOSE FOR EVALUATION:
Barbara is a 22-year-old recent college graduate. She is currently employed as an entry-level account representative in a large advertising agency, a job she recently started about three months ago in a large city in the Northeast. She made a self-referral for assessment, reporting that she has been feeling tired and lacking in energy for about four weeks. Barbara reported that two months ago she started missing college life and friends and was also feeling a dislike for her job. She further reported a loss of interest in socializing, making new friends, performing daily routines such as exercising and trouble with concentration. Barbara also found herself questioning her vocational choice and finds she has difficulty keeping her mind on her work. Barbara recognizes that this is not normal and realized the need to refer herself for professional help. A psychological assessment was requested to gain more information about her present functioning and to aid in a diagnosis and treatment plan for Barbara.
BEHAVIORAL OBSERVATIONS
Barbara arrived for her appointment on time and was open in discussing her history and present concerns. She did note that she had overslept and rushed to keep the appointment, so she had not eaten that morning. She completed the assessments in a thoughtful manner, occasionally asking clarifying questions. She had some difficulty in responding to the projective tests, stating she was worried she would give incorrect answers.
ASSESSMENT PROCEDURES
Weschler Adult Intelligence Scale - Fourth Edition
Clinical Assessment of Depression (CAD)
Myers-Briggs Type Indicator® Personal Impact Report
Sentence Completion Test
House Tree Person Test
Holland Code Career Test
INFORMATION ASSESSMENT TECHNIQUES
Development History Form
Interviews
Primary Sources Inventory
Review of medical reports
BACKGROUND INFORMATION
Family/Social:
Barbara reports no family history of emotional, behavioral, educational, substance or medical difficulties.
Education History:
Barbara finished elementary and high school with no reported issues and grades consisted of A’s and B’s. Barbara completed college and received her BA and reported grades of A’s and B’s. There was no history of learning or behavioral problems in school.
Medical History:
Barbara reports normal birth with no prematurity. No difficulties reported in birth. No reported use of alcohol or drugs while in utero. All developmental milestones were reached as normal. Barbara reports no history of injury or illness.
Current medical concerns Barbara reports are fatigue, sleep problems and low energy.
Psychiatric History:
Barbara reports ...
Comprehensive Client Family Assessment Demographic.docxAASTHA76
Comprehensive Client Family Assessment
Demographic information: Latino American family. Low socioeconomic status, working class.
Presenting problem: “Social worker believes our discipline style is too harsh and we need
parenting classes”
History of Present Illness: Both clients present to the office with concerns regarding their
children being “taken away” by social services as she believes they parent too harshly. They
adamantly proclaim that they are very good, loving parents but believe that when a child is not
following the rules, strict and physical discipline is necessary. They both explain that they were
brought up this way and that physical or emotional abuse is not present. They explain that this is
part of their culture and all they know is right. The social worker referred to the family as “those
Mexicans” and seemed to be bias towards the family. Also, she seemed to not consider any
alternative for the family after they requested it based on their working schedule and after
explaining their cultural belief system.
Past Psychiatric History: “Needs to be added to”
Medical History: “Needs to be added to”
Substance Abuse History: No indication for substance abuse. “Needs to be added to”
Developmental history: Parents report that their two sons all have met their milestones
throughout their development and are ages 6 and 8 years old. “Needs to be added to”
Family psychiatric history: “Needs to be added to”.
Psychosocial history: Male client works full-time and overtime to provide for the family. “Needs
to be added to”.
History of abuse/trauma: Based on the genogram created, both clients father and mother have a
history of disciplining their children similarly. They both would require the clients to hold
encyclopedias out in front of them until their arms “felt like they were going to fall off”. Both
clients report this type of discipline as being miserable and that they inherited this from their
parents. No physical or mental abuse of concern.
Review of Systems:
HEENT: No loss of vision or hearing. No sign of congestion, sore throat, or runny nose.
SKIN: Cool and dry skin with no signs of wounds or lesions.
CARDIOVASCULAR: No complaints of chest pain, tightness, discomfort or palpitations. S1,
S2 heard upon auscultation. 2+ pedal and radial pulses. No weight gain and no edema.
RESPIRATORY: Clear lung sounds with no adventitious sounds. No rhonchi or wheezes
auscultated, and chest is symmetrical. No cough present.
GASTROINTESTINAL: No nausea, emesis, or diarrhea. Abdomen soft, no distention, no
discomfort on palpation. Bowel sounds present in all four quadrants.
GENITOURINARY: No burning or discomfort when urinating.
NEUROLOGICAL: No double vision, headaches, seizures. No loss of memory. Alert and
oriented x person, place and time. Agitation present in male client.
MUSCULOSKELETAL: No joint or muscles pain. No g.
CASE STUDYFemale, 15, separation anxiety disorder, Depression.docxbartholomeocoombs
CASE STUDY:
Female, 15, separation anxiety disorder, Depression
The patient is a fifteen-year-old female teenager who presents to the clinic with her mother for her first assessment. Patient is being referral to the clinic by the school counselor due to low grades and poor school assistance. During the session, both the patient and the mother are neatly dressed. Her mother seems to be worried about her daughter. The patient said, "I worry a lot about my family members. I fear that one day my parents will be abducted or fatally injured. The worries and fears make me have difficulties concentrating on personal well-being and my studies in school." The mental assessment shows that the patient is depressed, and she refuses to leave the proximity of her mother. Her mother says that her daughter has been experiencing depression or anxiety attacks. The physical assessment shows that the patient has been experiencing physical aches and pains. She maintains good eye contact. Her mood is a little anxious. The symptoms conclude that the patient has separation anxiety disorder because the symptoms have progressed for the past six months. Treatments include antidepressants, group therapy, family therapy, dialectical behavioral therapy, and cognitive-behavioral therapy. A follow-up is to be done in two weeks.
Assignment 2: Focused SOAP Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
· Specifically address the following for the patient, using your SOAP note as a guide:
·
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
·
Objective: What observations did you make during the psychiatric assessment?
·
Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum o.
INITIAL CASE CONCEPTUALIZATION8Initial Case Conceptua.docxjaggernaoma
INITIAL CASE CONCEPTUALIZATION 8
Initial Case Conceptualization
Nichole Hairston-Purvis
Dr. Stephanie Warren
COUN6332
Capella University
February 12, 2018
PSYCHOLOGY
Part One: Client Information
This paper focuses on S. H., a client that the therapist has been speaking with in counselling sessions over a couple of weeks since they met during an internship program in the field. S.H. is 25 years of age. The client resides in Detroit City in Michigan, United States of America as a first generation immigrant, her country of origin being Nigeria in Africa. Having migrated into the U.S with her parents, 2 brothers and a sister when she was 11 years old, she is an African American citizen. She speaks both fluent English and Spanish. The client is a staunch Muslim and her wealthy parents live in New Jersey, U.S. S.H. has been working as a credit officer at a locally based bank until she was dimissed a few months ago .She rarely asks for financial support from her parents despite the fact that she is out of job.
The client does not portray any signs of physical disability and appears physically healthy. S.H. did not complete her college education after she got pregnant, arguing that she could not properly manage college, full time job and raising a baby. S.H.’s siblings are graduates having professional careers. The client has a son who is 2 years old and she claims that sometimes she feels ‘overwhelmed’ because of raising him all alone as her husband serves in the military and has been away for nine months. Client reveals that it has now been two years since she saw her family. Furthermore, she states that her relationship with her parents is ‘close’ despite mentioning that her father is an excessive drinker. Her father and mother are a banker and an educator respectively.
While presenting her concerns and problems the client said, “I lost my job a few months ago which has brought a feeling of hopelessness. I am having sleepless nights and I have lost my appetite.” Over the past two months, the client reported having lost eight pounds. Despite worrying about being a solo parent, she also fears that she might become homeless. S.H stated, “I am always worried. I am completely stressed out. My husband has been away for nine months serving in the military .I am always worried about him.” During her various appointments, S.H. has been arriving thirty minutes earlier. She also reported that she had never attended any counselling in the past. The client appeared to be suffering from depression and anxiety due to the fact that the client presented with shaky hands and was tearful during while completing her intake paperwork. During the description of her problems and her decision to seek out therapy, she made limited eye contact .She had a halting speech. The client seemed pretty willing and commitment to the nine treatment sessions recommended by her insurance company.
Part 2: Theoretical Framework
.
Informatics meshes technology and information into something usefu.docxannettsparrow
Informatics meshes technology and information into something useful. In nursing, informatics uses media such as health portals, mobile apps, social networking, and telehealth to aide nurses, patients and other stakeholders in decision making. When utilizing informatics our knowledge increases, we communicate better, we become more efficient with our job, and we provide better patient care.
As a hospice nurse, I often admit patients with very little to no medical history. My scenario would be to have a database that shares all health information for patients. If this would be available, decisions could be made that is in the best interest of the patient immediately and not have to wait for information to be sent. When having to wait, it impedes patient care and often has to backtrack and change the plan of care. Many times there is vital medical history missed because the patient/family member is a poor historian due to disease process or stress of the situation. If there is one database for all information potential medication errors could be avoided because you would know information such as allergies, current and previous medications prescribed.
This technology is already available to some extent in the prescription pain medicine world. The prescription drug monitoring program (PDMP) is a database that keeps track of controlled substances being prescribed. This is used in the fight against the opioid epidemic occurring today.
This idea is not new but has not come to fruition yet. If this was to occur, HIPPA would have to be strictly maintained. This could happen by having the patient sign an agreement allowing their information to be in the database and every provider having access to it. Many people travel even state to state and if there was a national database, all health records would be available at the fingertips of the provider no matter where the patient was allowing efficient and knowledgeable patient care.
Laureate Education (Producer). (2018). What is Informatics? [Video file]. Baltimore, MD: Author.
Laureate Education (Producer). (2018). Health Informatics and Population Health: Trends in Population Health [Video file]. Baltimore, MD: Author.
Discussion Topics, Mohr
Chapter 6, Culture
Discussion Topics
Learning Objective
1. During her first semester of nursing school, Felecia was assigned to a patient belonging to the American Indian culture. Felicia began to compare her own cultural beliefs with that of her patient.
a. To what ethnic, socioeconomic class, and community do you feel a part of or belong?
b. What are the values of your cultural group?
c. What are your attitudes toward people who are different from you in appearance or behavior?
1, 2, 10
2. When caring for an individual who belongs to a different culture, there may be variations in health concept and promotion.
a. List a cultural group, what their concept of health may be, and discuss variations as well as potential health promotion beliefs.
6
3. Maria is a .
Final Test and AssessmentNameUniversityDat.docxAKHIL969626
Final Test and Assessment
Name
University
Date
Running Head: FINAL TEST AND ASSESSMENT 1
FINAL TEST AND ASSESSMENT 6
Client: Barbara B.
Date of birth: 2/20/1993
Evaluated by:
Case No.: 1234
Date of Evaluation: 3/25/15
Date of Report: 2/25/18
PURPOSE FOR EVALUATION:
Barbara is a 22-year-old recent college graduate. She is currently employed as an entry-level account representative in a large advertising agency, a job she recently started about three months ago in a large city in the Northeast. She made a self-referral for assessment, reporting that she has been feeling tired and lacking in energy for about four weeks. Barbara reported that two months ago she started missing college life and friends and was also feeling a dislike for her job. She further reported a loss of interest in socializing, making new friends, performing daily routines such as exercising and trouble with concentration. Barbara also found herself questioning her vocational choice and finds she has difficulty keeping her mind on her work. Barbara recognizes that this is not normal and realized the need to refer herself for professional help. A psychological assessment was requested to gain more information about her present functioning and to aid in a diagnosis and treatment plan for Barbara.
BEHAVIORAL OBSERVATIONS
Barbara arrived for her appointment on time and was open in discussing her history and present concerns. She did note that she had overslept and rushed to keep the appointment, so she had not eaten that morning. She completed the assessments in a thoughtful manner, occasionally asking clarifying questions. She had some difficulty in responding to the projective tests, stating she was worried she would give incorrect answers.
ASSESSMENT PROCEDURES
Weschler Adult Intelligence Scale - Fourth Edition
Clinical Assessment of Depression (CAD)
Myers-Briggs Type Indicator® Personal Impact Report
Sentence Completion Test
House Tree Person Test
Holland Code Career Test
INFORMATION ASSESSMENT TECHNIQUES
Development History Form
Interviews
Primary Sources Inventory
Review of medical reports
BACKGROUND INFORMATION
Family/Social:
Barbara reports no family history of emotional, behavioral, educational, substance or medical difficulties.
Education History:
Barbara finished elementary and high school with no reported issues and grades consisted of A’s and B’s. Barbara completed college and received her BA and reported grades of A’s and B’s. There was no history of learning or behavioral problems in school.
Medical History:
Barbara reports normal birth with no prematurity. No difficulties reported in birth. No reported use of alcohol or drugs while in utero. All developmental milestones were reached as normal. Barbara reports no history of injury or illness.
Current medical concerns Barbara reports are fatigue, sleep problems and low energy.
Psychiatric History:
Barbara reports ...
Reply to Comment· Collapse SubdiscussionEmilia EgwimEmil.docxlillie234567
Reply to Comment
·
Collapse SubdiscussionEmilia Egwim
Emilia Egwim
8:33amDec 21 at 8:33am
Manage Discussion Entry
Discussion for Comprehensive Focused Soap Psychiatric Evaluation
Hello Lovelyne
Great presentation; I really enjoy reading your presentation about your patient Joey which is very informative. Autism Spectrum disorder is a neurodevelopmental disorder that is associated with tenacious predicaments in social communication and interaction in addition with limited, continual model of behaviors. According to study by Fitzpatrick et al; indicated that aggression behavior are noted to be increased in individual with ASD than when compared with other neurodevelopmental impairments (2016). This aggressive behavioral issues has been indicated by studies to relate with obstructive consequences for children diagnosed with ASD and their care providers resulting in reduced quality of life, heightened stress levels and decreased accessibility of educational and social adaptation/acceptance. Studies indicated that establishing effective therapeutic and pharmacological intervention approach for treatment as well as preventing aggressive behavior is imperative for reaching to better outcomes for individual with ASD. The patient in this case presentation had history of ASD and endorses aggression and self-injuries behaviors which have been indicated by various studies to associated with ASD and other manifestation including hyperactive, impulsive, inattentive behavior, unusual mood or emotional reaction.
To answer your question “
Is Risperidone FDA approved for patients with Autism”
Based on various studies, Risperidone and aripiprazole are approved by FDA and recommended for treatment of schizophrenia and bipolar for adult and adolescent including children with Autism Spectrum disorder around age 5 to 16 years. The Risperidone an antipsychotic medication was recommended to treat the aggression, irritability and mood swings associated with ASD. According to study; Risperidone has been effecting in treating symptoms of aggression and irritability between the age of 5 and 6 years distinctly that is associated with ASD, however, there’s no FDA approved medication for treatment of core sign and symptoms of ASD (Alayouf et al, 2021). There have been several controversy surrounding the use of Risperidone in which several clinician trials conducted reported that the medication was effective for the agitation, aggression and irritability often observed in autism patient, but was less effective in treating the core symptoms of Autism and other argument including the undesirable side effects that are associated with the medication and most significant of which is weight gain from an increased appetite. Other several medication as well as off-label prescription has been indicated to be effective such as treatment with SSRIs, CNS stimulants, NMDA-receptor antagonists, and including other agents (LeClerc & Easley, 2015). I completely agree with th.
Initial Psychiatric InterviewSOAP Note Template There are diff.docxLaticiaGrissomzz
Initial Psychiatric Interview/SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
Criteria
Clinical Notes
Informed Consent
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
Subjective
Verify Patient
Name:
DOB:
Minor:
Accompanied by:
Demographic:
Gender Identifier Note:
CC:
HPI:
Pertinent history in record and from patient: X
During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,
no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.
Allergies: NKDFA.
(medication & food)
Past Medical Hx:
Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported
Past Psychiatric Hx:
Previous psychiatric diagnoses: none reported.
Describes stable course of illness.
Previous medication trials: none reported.
Safety concerns:
History of Violence
to Self: none reported
History of Violence t
o Others: none reported
Auditory Hallucinations:
Visual Hallucinations:
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing.
The AssignmentAssign DSM-5 and ICD-10 codes to service.docxrtodd17
The Assignment
Assign
DSM-5
and ICD-10 codes to services based upon the patient case scenario.
Then, in 1–2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document.
Explain what pertinent information, generally, is required in documentation to support
DSM-5
and ICD-10 coding.
Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
Instructions
Use the following case template to complete Week 2 Assignment 1. On page 5, assign
DSM-5
and ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document.
Identifying Information
Identification was verified by stating of their name and date of birth.
Time spent for evaluation: 0900am-0957am
Chief Complaint
“My other provider retired. I don’t think I’m doing so well.”
HPI
25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.
Today, client denied symptoms of depression, denied anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking. Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self or engaging in anorexic behaviors. No self-mutilation behaviors.
Diagnostic Screening Results
Screen of symptoms in the past 2 weeks:
PHQ 9 = 0 with symptoms rated as no difficulty in functioning
Interpretation of Total Score
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression
GAD 7 = 2 with symptoms rated as no difficulty in fun.
Week 5 Focused SOAP Note and Patient Case Presentation Cosamirapdcosden
Week 5: Focused SOAP Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum
Introduction
Psychosis is a mental condition in which a person's ideas and perceptions are disrupted,
and the individual may have difficulty distinguishing between what is real and what is not.
A health condition, medications, or drug usage can all contribute to psychosis. Delusions,
hallucinations, incomprehensible speech, and agitation are all possible signs; the patient has
incorrect beliefs and sees or hears things that others do not see or hear. The person suffering from
the disease is usually unaware of his or her actions. Medication, psychotherapy, peer support,
family support and education, and talk therapy are all options for treatment. More or less every
mental intervention is backed by evidence accumulated during the patient's initial interview; each
patient's therapy begins with a thorough medical and mental health evaluation, the incorporation
of trust, and a discussion of past mental health history, substance misuse history, family mental
health history, and so on. In this example, the patient's evaluation was documented, and a
diagnosis was made based on the information collected from the patient during the evaluation.
When the case was being developed, a therapeutic approach was designed. The patient is a 53-
year-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after
his sister recommended a visit to the psychiatrist because patient's behavior changed since the
mother passed away.
Patient Initial: S.T Age: 53 Gender: Male
Subjective Data:
CC: "I was brought here by my sister because since my mother passed away, I was living on my
own and not bothering anyone. Those people outside my window they are after me. They just
want me dead".
HPI: When patient was asked " what people?". Patient said " the government sent them to get
me because my taxes are high". Suddenly patient asked the provider if she can see the birds or
hear any loud noise. The provider responded by redirecting the patient that she does not hear any
voice or see anything. When the provider how long he is been hearing the voices or seeing
things, patient said " for weeks, weeks and weeks". Patient also said the sister tapped her phone
with the government. When asked about sleep, patient said " I have not slept well because the
voices keep me up for days. I try to watch the TV, they poison my food on TV, I locked
everything down in the fridge". Suddenly patient asked " Can I smoke?". Provider said "no you
can't smoke here". Patient admit that he smokes all day about 3 packs a day. Drinks alcohol
which his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to
history of marijuana use 3 years ago before the m ...
PART1-Due ThursdayRespond to the following in a minimum of.docxJUST36
PART1-
D
ue Thursday
Respond to the following in a minimum of 175 words:
Review this week’s course materials and learning activities, and reflect on your learning so far this week. Respond to one or more of the following prompts in one to two paragraphs:
Provide citation and reference to the material(s) you discuss. Describe what you found interesting regarding this topic, and why.
Describe how you will apply that learning in your daily life, including your work life.
Describe what may be unclear to you, and what you would like to learn.
PART2-
University of Phoenix Material
Case Study Two Worksheet
Respond to the following questions in 1,250 to 1,500 words.
1. Why is this an ethical dilemma? Which APA Ethical Principles help frame the nature of the dilemma?
2. How might Irina’s age and parents’ involvement in the referral affect how Dr. Matthews can resolve the dilemma? How might the state law on treatment of minors and HIPAA rule on access of guardians to a minor’s health care record influence Dr. Matthews’ decision?
3. How are APA Ethical Standards 2.01a b, and c; 2.04; 3.04; 3.06; 4.01; 4.02; and 10.10a relevant to this case? Which other standards might apply?
4. What are Dr. Matthews’ ethical alternatives for resolving this dilemma? Which alternative best reflects the Ethics Code aspirational principle and enforceable standard, as well as legal standards and Dr. Matthews’ obligations to stakeholders?
5. What steps should Dr. Matthews take to ethically implement her decision and monitor its effects?
PART3-
Write
a 300-word or more paper in which you examine the legal aspects of record keeping and providing expert testimony. As part of your examination, address the following items:
Evaluate the legal issues associated with assessment, testing, and diagnosis documentation in professional psychology
Fisher, C. B. (2013).
Decoding the ethics code: A practical guide for psychologists
. Thousand Oaks, CA: Sage.
REFERENCE FOR PART 1
Psychologists aspire to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology and do not engage in subterfuge or intentional misrepresentation of fact (Principle C: Integrity). Standard 5.01a of the APA Ethics Code (APA, 2010b) prohibits false, deceptive, or fraudulent public statements regarding work activities or the activities of persons or organizations with which psychologists are affiliated.
The terms
avoidance
and
knowingly
exclude as violations statements that psychologists would reasonably be expected to believe are true but that they may later learn are false.
☑ A psychologist in a group practice distributed brochures with a listing of the group members’ credentials, only to discover that one member had submitted false credentials. She ceased distribution and ordered a corrected brochure.
☑ A research psychologist gave a public lecture, a series of media interviews, and congressional testimony during which he publicly .
1
6
Assignment template
Subjective Section
Chief complainant
The patient starts by saying, "I can't stop crying, all the time." The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her.
History of present illness (HPI)
L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently.
Past psychiatric history
The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure.
Medication trials and current medication
She has not tried any medications in the past, neither is she under any medication currently.
Psychotherapy or previous psychiatric diagnosis
The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder.
Pertinent substance use, social, and medical history
The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence.
Allergies
L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth.
ROS
General: No weight loss, fatigue or chills experienced by the patient.
HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay.
Skin: Her skin has not changed either is she having rashes.
Cardiovascular: No chest discomfort or pains.
Respiratory: She is not coughing or producing sputum, implying her respiratory is fine.
Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain.
Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains.
Hematologic: No bleeding realized or enlarged nodes.
Endocri ...
1
6
Assignment template
Subjective Section
Chief complainant
The patient starts by saying, "I can't stop crying, all the time." The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her.
History of present illness (HPI)
L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently.
Past psychiatric history
The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure.
Medication trials and current medication
She has not tried any medications in the past, neither is she under any medication currently.
Psychotherapy or previous psychiatric diagnosis
The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder.
Pertinent substance use, social, and medical history
The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence.
Allergies
L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth.
ROS
General: No weight loss, fatigue or chills experienced by the patient.
HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay.
Skin: Her skin has not changed either is she having rashes.
Cardiovascular: No chest discomfort or pains.
Respiratory: She is not coughing or producing sputum, implying her respiratory is fine.
Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain.
Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains.
Hematologic: No bleeding realized or enlarged nodes.
Endocri ...
AssignmentWrite a Respond to two of these #1&2 case studies.docxnormanibarber20063
Assignment:
Write a Respond to two of these #1&2 case studies using one or more of the following approaches:
Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
Suggest additional health-related risks that might be considered.
Validate an idea with your own experience and additional research.
Each must have at least 2 references no more than 5 years old using APA Format
Response # 1
“The case of physician do not heal thyself”
Three questions I will ask the patient on a visit to my office and rationale thereof.
Major depressive disorder (MDD) is defined as “feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home” and it is one of the most common reasons patients present for medical care worldwide (McConnell, Carter & Patterson, 2019). Childhood traumatic experiences, including physical, sexual, and emotional abuse, neglect, and separation from caregivers, they posit significantly increase the risk of developing mental and physical illnesses later in life.
NO .1
Have you had any thoughts of death or suicide before? Are you having them now? And do you have a current plan to harm or kill yourself? What are the details of that plan?
McConnell,et .al, (2019) posit that clients with MDD often presents with feeling sad or depressed; lack of interest or pleasure in previously enjoyed activities; appetite changes (unintentional weight loss or gain); sleep difficulty (too much or little); lack of energy (fatigue); feeling of guiltiness or worthlessness; moving more slowly or pacing (others observe); difficulty with decision-making, concentration, and thinking; and/or suicidal thoughts.
Patient safety remains a central concern in every healthcare setting (Smith,2018). This patient did report several feelings of Suicide Ideation and Homicidal ideation so patients’ safety should be priority. Although the welfare of patients encompasses a broad range of concerns, the increasing prevalence of suicide in our society compels health care workers to ensure a safe healthcare environment for patients with suicidal ideation. These efforts include the elimination or, at least, the mitigation of physical setting characteristics that enable suicide attempts.
No 2.
Are you depressed? How does this problem make you feel? What makes the problem better?
According to DSM-5 (2013) diagnostic criteria, MDD requires five or more of the following symptoms during the same two-week period and represent a change from previous functioning; at least one symptom is either 1) depressed mood or 2) loss of interest or pleasure (American Psychiatric Association [APA], 2013).
According to the patient’s file, he has experienced five or more of the symptoms of MDD during the same two-week period, on more than one occasion, incl.
NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Comprehensive Psychiatric Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
·
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
·
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5 diagnostic criteria for each differential diagnosis and explain what
DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the
initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety sympt.
Rogerian ArgumentTaken from the principles of psychologi.docxdaniely50
Rogerian Argument
Taken from the principles of psychologist Carl Rogers
Origins of this
principle
Based on Carl Rogers’ theory that people involved in disputes should not respond to each other until they fully and fairly state the other person’s position.
4 Parts of the Rogerian Argument
1. Introduction
2. Contexts
3. Writer’s position
4. Benefits to opponent
1. Introduction
The writer describes an issue well enough to show that he/she fully understands and respects the alternative position.
“Let’s meet in the middle.”
2. Contexts
The writer describes cases/contexts in which the alternative position may be legitimate.
“You may be right sometimes…”
3. Writer’s
Position
The writer states her/his position and presents circumstances in which it is valid. This is where the writer supports her/his views with evidence.
“This is why my position is right.”
4. Benefits to
Opponent
The writer explains to the opponent how he/she would benefit from adopting the writer’s position.
“See what you might gain by agreeing
with me?”
Summation
Rogerian arguments steer clear of incendiary and stereotypical language.
They emphasize how both sides of the argument might benefit by working together.
They advocate a win-win outcome.
1
Comprehensive Client Family Assessment
Demographic Information
Date of assessment: 09/14/2018.
DOB: 011/01/1970.
Age: 48.
Race: Black.
SSN: 000000001. Ethnicity: African American.
Address: On file. Tel: 972-000-0000.
Residential Status: Homeless.
County: 9K. Military Status: None.
Language: English.
Interpreter Needed: No.
Primary Insurance: Uninsured.
Annual Gross Income: $0.
Employment Status: Unemployed.
Number of people in the household: 1.
Highest Grade: 11.
School Attendance for the past 3 Months: None.
Arrival Time: 1000 Time Disposition Completed: 1100
Location of client: Lake Worth Nursing Home
Presenting Problem
“My meds are not working.”
History of Present Illness
The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife. The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013).
Past psychiatric history
1- Major Depressive disorder, Recurrent Episode with psychotic features
2- Alcohol use disorder; severe
3- Bipolar I Disorder most recent episode depressed Severe
Medical history
None Reported
Substance use history
Alcohol Abuse: began drinking at age 15 and drinks 8 to 10 bottles of beer daily, yesterday was his last time he drank.
Developmental history
None Reported
Family psychiatric history
Positive for family history of mental illness on the paternal side.
Psychosocial history
The patient is unemployed and enjoys han.
Ethics Case Study Essay GuideAs you prepare to write, please nBetseyCalderon89
Ethics Case Study Essay Guide
As you prepare to write, please note some formal aspects that should be present in your essay: 1) title your paper with a short sentence that frame the reader’s attention to the main topic of your essay; 2) in the introduction you should BRIEFLY state the nature of the ethical problem presented and how you are going to approach the case; 3) in the body of the essay, please provide brief description, critical analysis, and discussion. The discussion is the most important aspects of this assignment; and 4) in the conclusion, please wrap up your analysis and the insights you provided in your essay.
A complete essay will:
· Consider the ethical dilemmas confronting Anita Hill, Clarence Thomas, the Judiciary Committee, Joe Biden and any other stakeholders you see fit to name
· Clearly lay out values that you believe should govern an ethical society.
· Clearly lay out and prioritize your own ethical values and the categories or kinds of ethics these represent with relation to the societal ethical values you have laid out.
· Apply your ethical values and what you have been taught in this class about racism, sexism, economic inequality and other power differentials as well as cultural pathology and cultural racism to an evaluation of the decisions made by Anita Hill and Clarence Thomas and the Judiciary Committee considering the ethical dilemmas each was presented with.
· When laying out your argument you may want to consider such factors as the class disparities, race, income, gender roles, stereotypes, sentencing, elitism, etc.
· Conclude by stating and justifying your own ethical conclusions about the case and the kinds of ethics you utilized to arrive at those conclusions.
Please cite and reference all information that you use to help construct your essay particularly the course readings.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
· Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any lab ...
Reflective practice is the innovative way of learning through your own actions. This enhance the critical thinking abilities through forming strategies to overcome and prevent the same mistake happening again.
Chief Complaint Follow upHistory of Presenting IllnessMrJinElias52
Chief Complaint: Follow up
History of Presenting Illness:
Mr. Gerald is 58-year-old AA male admitted to SBGC on 10/8/21 due to history of HTN, chronic ETOH use, tobacco use, Wernicke's encephalopathy and unspecified psychiatric history. He was seen for follow up via telemedicine. He was selectively mute and could not talk to us much. Nodded head to most questions. Patient is a poor historian and has a history of given conflicting information. Staff report that appetite and sleep varies. He is being managed with Aricept 5mg for dementia and Cogentin 0.5mg for EPS. Ativan 1mg PRN for agitation. Nursing to continue to document behavior to direct further treatment plan. Verbalized understanding. No change in status. Denies suicidal or homicidal ideation. Denies any issue or discomfort currently. Patient denies current SI/HI/AVH/Paranoia/Delusion.
Current Medication: As per Matrix medication lists for medical.
Psychiatric medication: None
Past Psychiatric History: Unknown
Past Psychiatric Hospitalization: Unknown
History of Suicide Attempts or Thoughts- Unknown
Previous Psychiatric Medications: None PTSD: Y/N- Unknown.
Family Psychiatric History: Unknown
Medical History/Review of Systems: See Matrix for medical diagnosis.
Allergies Drug: NKDA.
Food Allergies: NKFA
Surgery: Y/N- Unknown. Sleep and Appetite Varies.
Normal Developmental History: None
Exposure to Drugs/medication/Alcohol: Y/N-Unknown
Speech/Language delays: Y/N- Yes
Sexual Abuse or Physical abuse: Y/N-Unknown
Social History: Unknown
Sexually active. Are you in relationship: Unknown?
Family Structure: Unknown
Favorite/Leisure activity: Y/N: Unknown
Educational History/Career: Unknown
Work history: Unknown
Substance Use History: Unknown.
Legal History: Y/N- Unknown
Mental Status Examination:
General Appearance: Neat & clean, casually dressed in good hygiene.
Eye contact: Normal Psychomotor Activity: Normal
Memory: Long term and short-term memory not intact. Attention: Reduced
SPEECH: Decreased speech in amount, rate, and volume.
MOOD: objectively Poor.
AFFECT: Flat and anxious.
THOUGHT PROCESS: Not appropriate.
THOUGHT CONTENT: Denies SI/HI.
PERCEPTIONS: Denies AVH sensorium.
INSIGHT: Poor
JUDGMENT: Poor
COGNITION: Poor
Language. normal.
Diagnosis:
F03.20 Dementia.
Suicidal ideation/HI - Denies Suicidal or homicidal ideation.
PROTECTIVE FACTORS: Family support
RISK ASSESSMENT: Low
SAFETY PLAN RECOMMENDATIONS: Notify staff if feeling Suicidal and call 911 for suicidal attempt.
Psychosis: - Denies Paranoia and delusional.
Prescription: No medication at this time.
Medication Education: Aricept 5mg at bed time for dementia. Cogentin 0.5mg for EPS. Ativan 1mg every 6hrs PRN.
Non-Pharmacological Education Recommended: Continue to use positive coping skills as needed. Identify triggers and address them proactively.
Plan: In 90 days, there will be improvement in memory and concentration.
Fall precaution in place
Follow up in 2 to 4 weeks.
NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation ...
Reply to Comment· Collapse SubdiscussionEmilia EgwimEmil.docxlillie234567
Reply to Comment
·
Collapse SubdiscussionEmilia Egwim
Emilia Egwim
8:33amDec 21 at 8:33am
Manage Discussion Entry
Discussion for Comprehensive Focused Soap Psychiatric Evaluation
Hello Lovelyne
Great presentation; I really enjoy reading your presentation about your patient Joey which is very informative. Autism Spectrum disorder is a neurodevelopmental disorder that is associated with tenacious predicaments in social communication and interaction in addition with limited, continual model of behaviors. According to study by Fitzpatrick et al; indicated that aggression behavior are noted to be increased in individual with ASD than when compared with other neurodevelopmental impairments (2016). This aggressive behavioral issues has been indicated by studies to relate with obstructive consequences for children diagnosed with ASD and their care providers resulting in reduced quality of life, heightened stress levels and decreased accessibility of educational and social adaptation/acceptance. Studies indicated that establishing effective therapeutic and pharmacological intervention approach for treatment as well as preventing aggressive behavior is imperative for reaching to better outcomes for individual with ASD. The patient in this case presentation had history of ASD and endorses aggression and self-injuries behaviors which have been indicated by various studies to associated with ASD and other manifestation including hyperactive, impulsive, inattentive behavior, unusual mood or emotional reaction.
To answer your question “
Is Risperidone FDA approved for patients with Autism”
Based on various studies, Risperidone and aripiprazole are approved by FDA and recommended for treatment of schizophrenia and bipolar for adult and adolescent including children with Autism Spectrum disorder around age 5 to 16 years. The Risperidone an antipsychotic medication was recommended to treat the aggression, irritability and mood swings associated with ASD. According to study; Risperidone has been effecting in treating symptoms of aggression and irritability between the age of 5 and 6 years distinctly that is associated with ASD, however, there’s no FDA approved medication for treatment of core sign and symptoms of ASD (Alayouf et al, 2021). There have been several controversy surrounding the use of Risperidone in which several clinician trials conducted reported that the medication was effective for the agitation, aggression and irritability often observed in autism patient, but was less effective in treating the core symptoms of Autism and other argument including the undesirable side effects that are associated with the medication and most significant of which is weight gain from an increased appetite. Other several medication as well as off-label prescription has been indicated to be effective such as treatment with SSRIs, CNS stimulants, NMDA-receptor antagonists, and including other agents (LeClerc & Easley, 2015). I completely agree with th.
Initial Psychiatric InterviewSOAP Note Template There are diff.docxLaticiaGrissomzz
Initial Psychiatric Interview/SOAP Note Template
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
Criteria
Clinical Notes
Informed Consent
Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion)
Subjective
Verify Patient
Name:
DOB:
Minor:
Accompanied by:
Demographic:
Gender Identifier Note:
CC:
HPI:
Pertinent history in record and from patient: X
During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
Patient self-esteem appears fair, no reported feelings of excessive guilt,
no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,
no reported changes in concentration or memory.
Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks.
Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.
SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.
Allergies: NKDFA.
(medication & food)
Past Medical Hx:
Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported
Past Psychiatric Hx:
Previous psychiatric diagnoses: none reported.
Describes stable course of illness.
Previous medication trials: none reported.
Safety concerns:
History of Violence
to Self: none reported
History of Violence t
o Others: none reported
Auditory Hallucinations:
Visual Hallucinations:
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing.
The AssignmentAssign DSM-5 and ICD-10 codes to service.docxrtodd17
The Assignment
Assign
DSM-5
and ICD-10 codes to services based upon the patient case scenario.
Then, in 1–2 pages address the following. You may add your narrative answers to these questions to the bottom of the case scenario document and submit altogether as one document.
Explain what pertinent information, generally, is required in documentation to support
DSM-5
and ICD-10 coding.
Explain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options.
Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.
Instructions
Use the following case template to complete Week 2 Assignment 1. On page 5, assign
DSM-5
and ICD-10 codes to the services documented. You will add your narrative answers to the assignment questions to the bottom of this template and submit altogether as one document.
Identifying Information
Identification was verified by stating of their name and date of birth.
Time spent for evaluation: 0900am-0957am
Chief Complaint
“My other provider retired. I don’t think I’m doing so well.”
HPI
25 yo Russian female evaluated for psychiatric evaluation referred from her retiring practitioner for PTSD, ADHD, Stimulant Use Disorder, in remission. She is currently prescribed fluoxetine 20mg po daily for PTSD, atomoxetine 80mg po daily for ADHD.
Today, client denied symptoms of depression, denied anergia, anhedonia, amotivation, no anxiety, denied frequent worry, reports feeling restlessness, no reported panic symptoms, no reported obsessive/compulsive behaviors. Client denies active SI/HI ideations, plans or intent. There is no evidence of psychosis or delusional thinking. Client denied past episodes of hypomania, hyperactivity, erratic/excessive spending, involvement in dangerous activities, self-inflated ego, grandiosity, or promiscuity. Client reports increased irritability and easily frustrated, loses things easily, makes mistakes, hard time focusing and concentrating, affecting her job. Has low frustration tolerance, sleeping 5–6 hrs/24hrs reports nightmares of previous rape, isolates, fearful to go outside, has missed several days of work, appetite decreased. She has somatic concerns with GI upset and headaches. Client denied any current binging/purging behaviors, denied withholding food from self or engaging in anorexic behaviors. No self-mutilation behaviors.
Diagnostic Screening Results
Screen of symptoms in the past 2 weeks:
PHQ 9 = 0 with symptoms rated as no difficulty in functioning
Interpretation of Total Score
Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression
GAD 7 = 2 with symptoms rated as no difficulty in fun.
Week 5 Focused SOAP Note and Patient Case Presentation Cosamirapdcosden
Week 5: Focused SOAP Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum
Introduction
Psychosis is a mental condition in which a person's ideas and perceptions are disrupted,
and the individual may have difficulty distinguishing between what is real and what is not.
A health condition, medications, or drug usage can all contribute to psychosis. Delusions,
hallucinations, incomprehensible speech, and agitation are all possible signs; the patient has
incorrect beliefs and sees or hears things that others do not see or hear. The person suffering from
the disease is usually unaware of his or her actions. Medication, psychotherapy, peer support,
family support and education, and talk therapy are all options for treatment. More or less every
mental intervention is backed by evidence accumulated during the patient's initial interview; each
patient's therapy begins with a thorough medical and mental health evaluation, the incorporation
of trust, and a discussion of past mental health history, substance misuse history, family mental
health history, and so on. In this example, the patient's evaluation was documented, and a
diagnosis was made based on the information collected from the patient during the evaluation.
When the case was being developed, a therapeutic approach was designed. The patient is a 53-
year-old Caucasian male who was scheduled for an initial screening for a psychotic disorder after
his sister recommended a visit to the psychiatrist because patient's behavior changed since the
mother passed away.
Patient Initial: S.T Age: 53 Gender: Male
Subjective Data:
CC: "I was brought here by my sister because since my mother passed away, I was living on my
own and not bothering anyone. Those people outside my window they are after me. They just
want me dead".
HPI: When patient was asked " what people?". Patient said " the government sent them to get
me because my taxes are high". Suddenly patient asked the provider if she can see the birds or
hear any loud noise. The provider responded by redirecting the patient that she does not hear any
voice or see anything. When the provider how long he is been hearing the voices or seeing
things, patient said " for weeks, weeks and weeks". Patient also said the sister tapped her phone
with the government. When asked about sleep, patient said " I have not slept well because the
voices keep me up for days. I try to watch the TV, they poison my food on TV, I locked
everything down in the fridge". Suddenly patient asked " Can I smoke?". Provider said "no you
can't smoke here". Patient admit that he smokes all day about 3 packs a day. Drinks alcohol
which his sister purchased for him to last him for weeks. Patient denies use of drugs. Admit to
history of marijuana use 3 years ago before the m ...
PART1-Due ThursdayRespond to the following in a minimum of.docxJUST36
PART1-
D
ue Thursday
Respond to the following in a minimum of 175 words:
Review this week’s course materials and learning activities, and reflect on your learning so far this week. Respond to one or more of the following prompts in one to two paragraphs:
Provide citation and reference to the material(s) you discuss. Describe what you found interesting regarding this topic, and why.
Describe how you will apply that learning in your daily life, including your work life.
Describe what may be unclear to you, and what you would like to learn.
PART2-
University of Phoenix Material
Case Study Two Worksheet
Respond to the following questions in 1,250 to 1,500 words.
1. Why is this an ethical dilemma? Which APA Ethical Principles help frame the nature of the dilemma?
2. How might Irina’s age and parents’ involvement in the referral affect how Dr. Matthews can resolve the dilemma? How might the state law on treatment of minors and HIPAA rule on access of guardians to a minor’s health care record influence Dr. Matthews’ decision?
3. How are APA Ethical Standards 2.01a b, and c; 2.04; 3.04; 3.06; 4.01; 4.02; and 10.10a relevant to this case? Which other standards might apply?
4. What are Dr. Matthews’ ethical alternatives for resolving this dilemma? Which alternative best reflects the Ethics Code aspirational principle and enforceable standard, as well as legal standards and Dr. Matthews’ obligations to stakeholders?
5. What steps should Dr. Matthews take to ethically implement her decision and monitor its effects?
PART3-
Write
a 300-word or more paper in which you examine the legal aspects of record keeping and providing expert testimony. As part of your examination, address the following items:
Evaluate the legal issues associated with assessment, testing, and diagnosis documentation in professional psychology
Fisher, C. B. (2013).
Decoding the ethics code: A practical guide for psychologists
. Thousand Oaks, CA: Sage.
REFERENCE FOR PART 1
Psychologists aspire to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology and do not engage in subterfuge or intentional misrepresentation of fact (Principle C: Integrity). Standard 5.01a of the APA Ethics Code (APA, 2010b) prohibits false, deceptive, or fraudulent public statements regarding work activities or the activities of persons or organizations with which psychologists are affiliated.
The terms
avoidance
and
knowingly
exclude as violations statements that psychologists would reasonably be expected to believe are true but that they may later learn are false.
☑ A psychologist in a group practice distributed brochures with a listing of the group members’ credentials, only to discover that one member had submitted false credentials. She ceased distribution and ordered a corrected brochure.
☑ A research psychologist gave a public lecture, a series of media interviews, and congressional testimony during which he publicly .
1
6
Assignment template
Subjective Section
Chief complainant
The patient starts by saying, "I can't stop crying, all the time." The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her.
History of present illness (HPI)
L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently.
Past psychiatric history
The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure.
Medication trials and current medication
She has not tried any medications in the past, neither is she under any medication currently.
Psychotherapy or previous psychiatric diagnosis
The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder.
Pertinent substance use, social, and medical history
The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence.
Allergies
L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth.
ROS
General: No weight loss, fatigue or chills experienced by the patient.
HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay.
Skin: Her skin has not changed either is she having rashes.
Cardiovascular: No chest discomfort or pains.
Respiratory: She is not coughing or producing sputum, implying her respiratory is fine.
Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain.
Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains.
Hematologic: No bleeding realized or enlarged nodes.
Endocri ...
1
6
Assignment template
Subjective Section
Chief complainant
The patient starts by saying, "I can't stop crying, all the time." The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her.
History of present illness (HPI)
L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently.
Past psychiatric history
The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure.
Medication trials and current medication
She has not tried any medications in the past, neither is she under any medication currently.
Psychotherapy or previous psychiatric diagnosis
The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder.
Pertinent substance use, social, and medical history
The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence.
Allergies
L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth.
ROS
General: No weight loss, fatigue or chills experienced by the patient.
HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay.
Skin: Her skin has not changed either is she having rashes.
Cardiovascular: No chest discomfort or pains.
Respiratory: She is not coughing or producing sputum, implying her respiratory is fine.
Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain.
Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains.
Hematologic: No bleeding realized or enlarged nodes.
Endocri ...
AssignmentWrite a Respond to two of these #1&2 case studies.docxnormanibarber20063
Assignment:
Write a Respond to two of these #1&2 case studies using one or more of the following approaches:
Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
Suggest additional health-related risks that might be considered.
Validate an idea with your own experience and additional research.
Each must have at least 2 references no more than 5 years old using APA Format
Response # 1
“The case of physician do not heal thyself”
Three questions I will ask the patient on a visit to my office and rationale thereof.
Major depressive disorder (MDD) is defined as “feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home” and it is one of the most common reasons patients present for medical care worldwide (McConnell, Carter & Patterson, 2019). Childhood traumatic experiences, including physical, sexual, and emotional abuse, neglect, and separation from caregivers, they posit significantly increase the risk of developing mental and physical illnesses later in life.
NO .1
Have you had any thoughts of death or suicide before? Are you having them now? And do you have a current plan to harm or kill yourself? What are the details of that plan?
McConnell,et .al, (2019) posit that clients with MDD often presents with feeling sad or depressed; lack of interest or pleasure in previously enjoyed activities; appetite changes (unintentional weight loss or gain); sleep difficulty (too much or little); lack of energy (fatigue); feeling of guiltiness or worthlessness; moving more slowly or pacing (others observe); difficulty with decision-making, concentration, and thinking; and/or suicidal thoughts.
Patient safety remains a central concern in every healthcare setting (Smith,2018). This patient did report several feelings of Suicide Ideation and Homicidal ideation so patients’ safety should be priority. Although the welfare of patients encompasses a broad range of concerns, the increasing prevalence of suicide in our society compels health care workers to ensure a safe healthcare environment for patients with suicidal ideation. These efforts include the elimination or, at least, the mitigation of physical setting characteristics that enable suicide attempts.
No 2.
Are you depressed? How does this problem make you feel? What makes the problem better?
According to DSM-5 (2013) diagnostic criteria, MDD requires five or more of the following symptoms during the same two-week period and represent a change from previous functioning; at least one symptom is either 1) depressed mood or 2) loss of interest or pleasure (American Psychiatric Association [APA], 2013).
According to the patient’s file, he has experienced five or more of the symptoms of MDD during the same two-week period, on more than one occasion, incl.
NRNP/PRAC 6645 Comprehensive Psychiatric
Evaluation Note Template
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the
Comprehensive Psychiatric Evaluation Template
AND the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.
In the
Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
·
Read rating descriptions to see the grading standards!
In the
Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
·
Read rating descriptions to see the grading standards!
In the
Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5 diagnostic criteria for each differential diagnosis and explain what
DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
·
Read rating descriptions to see the grading standards!
Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the
initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety sympt.
Rogerian ArgumentTaken from the principles of psychologi.docxdaniely50
Rogerian Argument
Taken from the principles of psychologist Carl Rogers
Origins of this
principle
Based on Carl Rogers’ theory that people involved in disputes should not respond to each other until they fully and fairly state the other person’s position.
4 Parts of the Rogerian Argument
1. Introduction
2. Contexts
3. Writer’s position
4. Benefits to opponent
1. Introduction
The writer describes an issue well enough to show that he/she fully understands and respects the alternative position.
“Let’s meet in the middle.”
2. Contexts
The writer describes cases/contexts in which the alternative position may be legitimate.
“You may be right sometimes…”
3. Writer’s
Position
The writer states her/his position and presents circumstances in which it is valid. This is where the writer supports her/his views with evidence.
“This is why my position is right.”
4. Benefits to
Opponent
The writer explains to the opponent how he/she would benefit from adopting the writer’s position.
“See what you might gain by agreeing
with me?”
Summation
Rogerian arguments steer clear of incendiary and stereotypical language.
They emphasize how both sides of the argument might benefit by working together.
They advocate a win-win outcome.
1
Comprehensive Client Family Assessment
Demographic Information
Date of assessment: 09/14/2018.
DOB: 011/01/1970.
Age: 48.
Race: Black.
SSN: 000000001. Ethnicity: African American.
Address: On file. Tel: 972-000-0000.
Residential Status: Homeless.
County: 9K. Military Status: None.
Language: English.
Interpreter Needed: No.
Primary Insurance: Uninsured.
Annual Gross Income: $0.
Employment Status: Unemployed.
Number of people in the household: 1.
Highest Grade: 11.
School Attendance for the past 3 Months: None.
Arrival Time: 1000 Time Disposition Completed: 1100
Location of client: Lake Worth Nursing Home
Presenting Problem
“My meds are not working.”
History of Present Illness
The patient is presenting with suicidal ideation with a plan and intent to jump off the bridge or self-stabs with a knife. The patient complained about his medication, Latuda is no longer working. Currently homeless with no job or income. Though calm, polite, and cooperative with organized thoughts, patient reports depression and anxiety (American Psychiatric Association, 2013).
Past psychiatric history
1- Major Depressive disorder, Recurrent Episode with psychotic features
2- Alcohol use disorder; severe
3- Bipolar I Disorder most recent episode depressed Severe
Medical history
None Reported
Substance use history
Alcohol Abuse: began drinking at age 15 and drinks 8 to 10 bottles of beer daily, yesterday was his last time he drank.
Developmental history
None Reported
Family psychiatric history
Positive for family history of mental illness on the paternal side.
Psychosocial history
The patient is unemployed and enjoys han.
Ethics Case Study Essay GuideAs you prepare to write, please nBetseyCalderon89
Ethics Case Study Essay Guide
As you prepare to write, please note some formal aspects that should be present in your essay: 1) title your paper with a short sentence that frame the reader’s attention to the main topic of your essay; 2) in the introduction you should BRIEFLY state the nature of the ethical problem presented and how you are going to approach the case; 3) in the body of the essay, please provide brief description, critical analysis, and discussion. The discussion is the most important aspects of this assignment; and 4) in the conclusion, please wrap up your analysis and the insights you provided in your essay.
A complete essay will:
· Consider the ethical dilemmas confronting Anita Hill, Clarence Thomas, the Judiciary Committee, Joe Biden and any other stakeholders you see fit to name
· Clearly lay out values that you believe should govern an ethical society.
· Clearly lay out and prioritize your own ethical values and the categories or kinds of ethics these represent with relation to the societal ethical values you have laid out.
· Apply your ethical values and what you have been taught in this class about racism, sexism, economic inequality and other power differentials as well as cultural pathology and cultural racism to an evaluation of the decisions made by Anita Hill and Clarence Thomas and the Judiciary Committee considering the ethical dilemmas each was presented with.
· When laying out your argument you may want to consider such factors as the class disparities, race, income, gender roles, stereotypes, sentencing, elitism, etc.
· Conclude by stating and justifying your own ethical conclusions about the case and the kinds of ethics you utilized to arrive at those conclusions.
Please cite and reference all information that you use to help construct your essay particularly the course readings.
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
· Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any lab ...
Reflective practice is the innovative way of learning through your own actions. This enhance the critical thinking abilities through forming strategies to overcome and prevent the same mistake happening again.
Chief Complaint Follow upHistory of Presenting IllnessMrJinElias52
Chief Complaint: Follow up
History of Presenting Illness:
Mr. Gerald is 58-year-old AA male admitted to SBGC on 10/8/21 due to history of HTN, chronic ETOH use, tobacco use, Wernicke's encephalopathy and unspecified psychiatric history. He was seen for follow up via telemedicine. He was selectively mute and could not talk to us much. Nodded head to most questions. Patient is a poor historian and has a history of given conflicting information. Staff report that appetite and sleep varies. He is being managed with Aricept 5mg for dementia and Cogentin 0.5mg for EPS. Ativan 1mg PRN for agitation. Nursing to continue to document behavior to direct further treatment plan. Verbalized understanding. No change in status. Denies suicidal or homicidal ideation. Denies any issue or discomfort currently. Patient denies current SI/HI/AVH/Paranoia/Delusion.
Current Medication: As per Matrix medication lists for medical.
Psychiatric medication: None
Past Psychiatric History: Unknown
Past Psychiatric Hospitalization: Unknown
History of Suicide Attempts or Thoughts- Unknown
Previous Psychiatric Medications: None PTSD: Y/N- Unknown.
Family Psychiatric History: Unknown
Medical History/Review of Systems: See Matrix for medical diagnosis.
Allergies Drug: NKDA.
Food Allergies: NKFA
Surgery: Y/N- Unknown. Sleep and Appetite Varies.
Normal Developmental History: None
Exposure to Drugs/medication/Alcohol: Y/N-Unknown
Speech/Language delays: Y/N- Yes
Sexual Abuse or Physical abuse: Y/N-Unknown
Social History: Unknown
Sexually active. Are you in relationship: Unknown?
Family Structure: Unknown
Favorite/Leisure activity: Y/N: Unknown
Educational History/Career: Unknown
Work history: Unknown
Substance Use History: Unknown.
Legal History: Y/N- Unknown
Mental Status Examination:
General Appearance: Neat & clean, casually dressed in good hygiene.
Eye contact: Normal Psychomotor Activity: Normal
Memory: Long term and short-term memory not intact. Attention: Reduced
SPEECH: Decreased speech in amount, rate, and volume.
MOOD: objectively Poor.
AFFECT: Flat and anxious.
THOUGHT PROCESS: Not appropriate.
THOUGHT CONTENT: Denies SI/HI.
PERCEPTIONS: Denies AVH sensorium.
INSIGHT: Poor
JUDGMENT: Poor
COGNITION: Poor
Language. normal.
Diagnosis:
F03.20 Dementia.
Suicidal ideation/HI - Denies Suicidal or homicidal ideation.
PROTECTIVE FACTORS: Family support
RISK ASSESSMENT: Low
SAFETY PLAN RECOMMENDATIONS: Notify staff if feeling Suicidal and call 911 for suicidal attempt.
Psychosis: - Denies Paranoia and delusional.
Prescription: No medication at this time.
Medication Education: Aricept 5mg at bed time for dementia. Cogentin 0.5mg for EPS. Ativan 1mg every 6hrs PRN.
Non-Pharmacological Education Recommended: Continue to use positive coping skills as needed. Identify triggers and address them proactively.
Plan: In 90 days, there will be improvement in memory and concentration.
Fall precaution in place
Follow up in 2 to 4 weeks.
NRNP/PRAC 6645 Comprehensive Psychiatric Evaluation ...
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Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
1. Describe each client (without violating HIPAA regulations)
Describe each client (without violating HIPAA regulations)Describe each client (without
violating HIPAA regulations)Permalink: https:// /describe-each-cl…ipaa-
regulations/Describe each client (without violating HIPAA regulations)Students
will:Develop effective documentation skills for group therapy sessions *Develop diagnoses
for clients receiving group psychotherapy *Evaluate the efficacy of cognitive behavioral
therapy for groups *Analyze legal and ethical implications of counseling clients with
psychiatric disorders ** The Assignment related to this Learning Objective is introduced
this week and submitted in Week 10.Select two clients you observed or counseled this week
during a group therapy session. Note: The two clients you select must have attended the
same group session.Then, in your Practicum Journal, address the following:Using the Group
Therapy Progress Note in this week’s Learning Resources, document the group
session.Describe each client (without violating HIPAA regulations), and identify any
pertinent history or medical information, including prescribed medications.Using the DSM-
5, explain and justify your diagnosis for each client.Explain whether cognitive behavioral
therapy would be effective with this group. Include expected outcomes based on this
therapeutic approach.Explain any legal and/or ethical implications related to counseling
each client.Support your approach with evidence-based literature Describe each client
(without violating HIPAA regulations)Psychotherapy with groups and familiesPart 1.The
case involved a family that sought psychotherapy for spousal and domestic abuse. The
family seeking therapy is comprised of two members. The first member is the mother,
Maria, a 24 year old women of Latino descent. She is a housewife with no marketable skills
and moved into the country seven years ago upon getting married to her husband. She
reports that her husband has been physically and emotionally abusive towards her. He does
not allow her to have friends of contact with her family. She further adds that the abuse has
escalated to an extent that she feared for her life. Although she is currently separated from
her husband after the police intervened after the neighbors made repeated reports to them.
She is fearful that she does not have any marketable skills or a social support system in
place thus making her vulnerable to manipulation from her husband. She is not on any
prescription medication Describe each client (without violating HIPAA regulations).The
second member is the daughter, Angela, a 7 year old child. She is non-communicative and
appears fearful in the presence of adult males. She has scars from beatings by her father.
She is not on any prescription medication.Part 2.Using DSM-5, Maria has been diagnosed as
suffering from intimate partner violence. The diagnosis is based on the set criteria that
2. includes being subjected to violence and aggression from an intimate partner who was her
husband in this case. She has experienced severe and chronic episodes of spousal violence
over the course of her marriage. To be more precise, she meets two out of four conditions
for this diagnosis. Besides that, she has been repeatedly subjected to emotional abuse
(psychological aggression). These aspects of her relationship support the diagnosis (Sperry,
2016).Using DSM-5, Angela has been diagnosed as suffering from child physical and
psychological abuse. This diagnosis is based on the scars on her body that act as evidence of
physical abuse. In addition, her fear of male adults and non-communicative nature are
evidence that she has been psychologically abused by her father (Sperry, 2016). Describe
each client (without violating HIPAA regulations).Part 3.The family therapy should apply
cognitive behavioral therapy (CBT) as an appropriate approach. The family are victims of
physical and psychological abuse that was targeted at controlling them. This had a negative
effect on their behaviors, emotions and thoughts. CBT addresses the negative effects of the
abuse through applying a stepwise methodology that identifies the problem, reflects on past
abuse, evaluates how the abuse was justified, reflecting on how emotions affected thoughts
that ultimately affected behavior, and developing self-talk that changes and challenges the
negative emotions to protect the clients (Wheeler, 2014).Part 4.Counseling Maria has legal
implications over confidentiality and disclosures. The abuse has legal implications and there
could be sensational details that the counselor is obligated to report to law enforcement
officers. This is particularly the case if the abuse is still ongoing and the police are not
aware. This could be challenging since Maria has been assured of confidentiality and that
none of the information she discloses will be shared with a third party without her prior
informed permission (Cautlin & Lilienfeld, 2015). Describe each client (without violating
HIPAA regulations).Counseling Angela has ethical implications. She is a child and issues of
informed consent come into play since she is not consulted on whether or not she wants to
attend therapy. In addition, there is an issue of confidentiality since the mother expects to
be informed about the case details even if Angela expresses a desire to have all the case
details kept confidential and not disclosed to other parties (Cautlin & Lilienfeld,
2015).ReferencesCautin, R. & Lilienfeld, S. (2015). The encyclopedia of clinical psychology,
volume II Cli-E. Hoboken, NJ: John Wiley & Sons.Sperry, L. (2016). Handbook of diagnosis
and treatment of DSM-5 personality disorders: assessment, case conceptualization, and
treatment (3rd ed.). New York, NY: Routledge.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, LLC. Describe each client
(without violating HIPAA regulations). Students will:Develop effective documentation skills
to examine group therapy sessions with children and adolescents *Develop diagnoses for
child and adolescent clients receiving group psychotherapy *Analyze legal and ethical
implications of counseling child and adolescent clients with psychiatric disorders *Select
two clients you observed or counseled this week during a group therapy session for
children and adolescents. Note: The two clients you select must have attended the same
group session. If you select the same group you selected for the Week 8 or Week 9 Journal
Entries, you must select different clients Describe each client (without violating HIPAA
regulations).Then, address in your Practicum Journal the following:Using the Group
3. Therapy Progress Note in this week’s Learning Resources, document the group
session.Describe each client (without violating HIPAA regulations), and identify any
pertinent history or medical information, including prescribed medications.Using the DSM-
5, explain and justify your diagnosis for each client.Explain any legal and/or ethical
implications related to counseling each client.Support your approach with evidence-based
literatureDescribe each client (without violating HIPAA regulations) Group Therapy
Sessions with Children and AdolescentsDescription of clients, identifying any pertinent
history or medical informationClient A, a seven-year-old girl presented to the hospital
psychiatric department with a history of feeling anxious when not together with her mother
and sleeping away from home. This happened when the girl slept at a friend’s or relative’s
home or while in a school camp. She expressed her nervousness as a worry that something
bad would happen to her mother. Whether the detachment had was anticipated or had
occurred, the client and her mother stated that she would experience worry, fear, stomach
churning, crying, trembling and sweating. At the period of consultation, the client was not
under any medication and medical history revealed that the client did not have any other
clinically significant feature.Client B, a twelve- year old boy was brought to the pediatrician
by his mother who was concerned that the boy is no longer rides bikes or play with toys
with other children in the neighborhood. Over the last one month, the boy has been
isolating himself and has become more irritable with no recognized trigger, has complained
of frequent stomachaches and headaches over the last numerous weeks, and worries that all
people in the family will die. Teachers have reported inattentiveness and impulsive
behaviors in the class. The boy has also been having random durations of uncontrollable
screaming and crying with no trigger Describe each client (without violating HIPAA
regulations). There doesn’t exist a history of trauma, psychotic medication, changes in
everyday life or recent losses.An explanation and justification diagnosis for each client using
the DSM-5Client A is suffering from separation anxiety disorder (SAD). The DMS-5 defines
SAD as a developmentally unsuitable and excessive nervousness about separation from
home or from those to whom the patient is attached. According to Cooper-Vince et al
(2014), diagnostic criteria describe excessive anxiety associated with separation as
demonstrated by the existence of at least three of the specified SAD symptoms. These
symptoms include recurrent extreme distress when separation from key attachment
figures or home is anticipated or occurs, excessive and persistent worry anxiousness about
losing or on probable harm happening to a key attachment figure, excessive and persistent
nervousness that an untoward incident will result in separation from the key attachment
figure and persistent refusal or reluctance to go elsewhere for fear of being separated.
Other symptoms include excessively and persistently reluctant or fearful of not being with
key attachment figures or at home and frequent reports of physical symptoms like vomiting,
nausea, stomachaches, and headaches when a detachment from key attachment figures is
anticipated or occurs. Describe each client (without violating HIPAA regulations).Client B is
suffering from major depressive disorder (MDD). As Fatemi and Clayton (2016) indicate,
according to the DSM-5 diagnostic criteria for MDD include the presence of at least five
depressive symptoms for two or more weeks. These symptoms include the existence of
irritable/depressed mood or anhedonia, reduced along with other depressive symptoms
4. like reduced capability to have fun, sleep disturbance, impaired social relationships or social
withdrawal suicidal ideation or thoughts of death, lack of energy, poor concentration. These
symptoms should not be as a result of the effects of medication, drug or alcohol use, or a
universal medical illness.Ethical and legal implications related to counseling clientsA key
ethical implication related to counselling both clients is competency. According to Ziomek-
Daigle (2017), it is the ethical responsibility of children and adolescent psychotherapist to
ensure that they have the proper treating and competency in child and adolescent
psychotherapy. There exist diverse systems, such as school, peers, community and family
interacting with the child. Successful and adolescent psychotherapy needs specialized skills
and knowledge in counselling these populating along with a thorough knowledge of the
bigger systemic context affect the adolescent’s life and behavior Describe each client
(without violating HIPAA regulations).Confidentiality and informed consent are other major
ethical issues when counselling children and adolescents. it is a legal and ethical
responsibility for a counselor to get informed consent from clients utilizing a language they
are able to understand. As Sori and Hecker (2015) allege, children and adolescents who
have not reached the legal age of giving consent, the counselor is required to obtain consent
from the parent, but the child must agree to take part in counselling. Sori and Hecker (2015)
claim that confidentiality issues are intricate in treating children and adolescents because
their legal guardians or parents are usually involved in the counselling process and can
access their medical records. Therefore, the counselor must maintain a balance amid the
ethical responsibility of informing the parents on any treatment performed and the
progress of the treatment, and the clients’ right to autonomy and privacy. Describe each
client (without violating HIPAA regulations). ReferencesCooper-Vince, C., Emmert-
Arponson, B., Pincus, D., & Comer, J. (2014). The diagnostic utility of separation anxiety
disorder symptoms: An item response theory analysis. Journal of Abnormal Child
Psychology, 42(3): 417-248Fatemi, S., & Clayton, P. (2016). The Medical Basis of
Psychiatry. New York: Springer.Sori, C., & Hecker, L. (2015). Ethical and Legal
Considerations When Counselling Children and Families. Australian and New Zealand
Journal of Family Therapy, 36(4): 450-464.Ziomek-Daigle, J. (2017). Counselling Children
and Adolescents: Working in School and Clinical Mental Health Settings. Boca Raton,
FL: Taylor & Francis. Describe each client (without violating HIPAA regulations).