please this is my last chance to resubmit this assignment. please pay attention to the comment below ——this assignment is a Mental health comprehensive assessment —–your HPI needs more comprehe
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please this is my last chance to resubmit this assignment. please pay attention to the comment below
——this assignment is a Mental health comprehensive assessment
—–your HPI needs more comprehensive information.
—–I should be able to understand the differential diagnosis from your HPI.
(please explain the differential diagnoses)
—–Needs more information in the MSE section
——please complete the genogram part 2
——at least 5 references list need not more than 5 years
——Zero plagiarism
The Assignment
Part 1: Comprehensive Client Family Assessment
With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations):
- Demographic information
- Presenting problem
- History or present illness
- Past psychiatric history
- Medical history
- Substance use history
- Developmental history
- Family psychiatric history
- Psychosocial history
- History of abuse/trauma
- Review of systems
- Physical assessment
- Mental status exam
- Differential diagnosis
- Case formulation
- Treatment plan
Part 2: Family Genogram
Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).
Learning Resources
Required Readings
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
————use scenerio below
HPI:Patient is a 30 year old female, seen via telehealth, patient gave verbal consent for treatment, patient report she suffers alot of anxiety and suffers from eating disorder, patient reported she use to be a model and she was being critized about her bad and that resulted to her eating disorder, she began binge eating sometimes she goes for days without food so once she eats she will binge , patient report her weight freaks her out, patient report gaining wieght freeks her out.Patient report she skip eating and she is very picky to maintained her weight.patient report she is currently 119 Ibs and her goal weight is one 118 pound. Patient reprot she suffers alot of anxiety , and her mother recently passed away and it has been hard for her to accept that her mother isno more, patient report when she experience death in the family, it stop her from eating , patient report she has not been sleeping well , patient report being depressed , feeling down, social isolates .patient report social anxiety disorder .Patient reported she is thinking of chnaging her names, she does not react very well to death, and she does not feel connected to her name .Patient denies any suicidal or homicidal ideation, plan or intent, denied visual of auditory hallucination. Denies somatic complaints (headache, fatigue, stomachache, etc.)
Past Psychiatric History:
Past Diagnosis: eating , disorder, anxiety and depression
Hospitalizations: hospitalized a year ago for depression and eating disorder
History of suicides: none
History of Violence: No
History of self-mutilation: no
Outpatient Rx with a Psychiatrist: patient was receiving treatment from a psychiatrist Nurse practitioner
Psychotherapy: currently at Pathways in Hollywood
Medications trials in the past:lexapro ,lovox,
Current psychotropics: mirtazapine, klonopin ,prochlorperazine
Medication History:
Date
Medication
Sig
#
Refill
Status
06/25/2020
Zoloft 25 mg tablet
1 tablet by mouth daily
30
0
Active
06/25/2020
Remeron 15 mg tablet
1 tablet by mouth nightly
30
0
Active
06/25/2020
prochlorperazine maleate 10 mg tablet
1 tablet by mouth daily
0
Active
Allergies:
patient reproted she is allergic to red colour food or pills
Social History:
Social: Patient is single , no kids
Develpmental: born and raised in Maryland
Alcohol: drinks occassionally
Drug: ; Denies
Abuse: denies
Faith: christian
Occupation: unemployed
Education: High school diploma
Legal: Denies
Family History:
patient denies any family history of mental or medical problems
Review of Systems:
Constitutional
Denied:
Chills. Decline in Health. Fatigue. Fever. Malaise. Other abnormal constitutional symptoms. Weakness. Weight Gain. Weight loss.
Eyes
Denied:
Blurry Vision. Cataracts. Discharge. Double Vision. Excessive tearing. Eye Pain. Eyeglass Use. Glaucoma. Infections. Pain with Light. Recent Injury. Redness. Unusual sensations. Vision Loss.
Respiratory
Denied:
Asthma. Bronchitis. Cough. Coughing Blood. Pain. Pleurisy. Positive TB Test. Recent Chest X-Ray. Short of Breath. Sputum. Tuberculosis. Wheezing.
Cardiovascular
Denied:
Chest Pain. Extremity(s) Cool. Extremity(s) Discolored. Hair loss on legs. Heart murmur. Heart Tests (Not EKG). High blood pressure. history of heart attack. Leg Pain – Walking. Palpitations. Recent Electrocardiogram. Rheumatic fever. Short of Breath – Exertion. Short of Breath – Lying Flat. Short of Breath – Sleeping. Swelling of legs. Thrombophlebitis. ulcers on legs. Varicose veins.
Gastrointestinal
Denied:
Abdominal Pain. Abdominal X-Ray Tests. Antacid Use. Black Tarry Stools. Change in Frequency of BM. Change in stool caliber. Change in stool color. Change in stool consistency. Constipation. Decreased Appetite. Diarrhea. Excessive Hunger. Excessive Thirst. Gallbladder Disease. Heartburn. Hemorrhoids. Hepatitis. Infections. Jaundice. Laxative Use. Liver Disease. Nausea. Rectal Bleeding. Rectal Pain. Swallowing Problem. Vomiting. Vomiting Blood.
Musculoskeletal
Reported:
joint problems.
Denied:
disturbances of gait or station. muscle strength. tone.
Psychiatric
Reported:
Depression. Nervousness. Mood changes.
Denied:
Behavioral Change. compulsive. delusions. depressive symptoms. Disorientation. Disturbing thoughts. Excessive stress. Hallucinations. intrusive. manic symptoms. Memory loss. persistent thoughts. Psychiatric disorders. ritualistic acts. suicidal ideas or intentions.
Skin
Reported:
Easting disorder ,scolliosis , seizures
Denied:
Dryness. Eczema. Hair dye. Hair texture change. Hives. Itching. Lumps. Mole Increased Size. nail appearance change. nail texture change. Rashes. Skin Color Change.
Neurological
Reported:
seizures disorder
Denied:
Blackouts. Burning. Dizziness. Fainting. Head Injury. Headaches. Loss of consciousness. Memory loss. Numbness. Paralysis. Speech disorders. Strokes. Tingling. Tremors. Unsteady gait.
Endocrine
Denied:
Cold intolerance. Excessive Urination. Fatigue. Goiter. Heat intolerance. Increased Thirst. Neck Pain. Sweats. Thyroid Trouble. Weakness. Weight gain. Weight loss.
Hematologic/Lymph
Denied:
Anemia. Bleeding easily. Blood clots. Easy bruisability. Lumps. Radiation Exposure. Swollen glands. Transfusion reaction.
Allergic/Immunologic
Denied:
Coughing. Coughing with Exercise. Hives. Itchy Eyes. Itchy Nose. Recurrent infections. Runny Nose. Sneezing. Stuffy Nose. Watery Eyes. Wheezing. Wheezing with exercise.
Genitourinary
Urinary
Denied:
Awakening to Urinate. Bed-Wetting. Blood in Urine. Burning. Difficulty Starting Stream. Excessive Urination. Flank Pain. Frequency. Incontinence. Infections. Pain on Urination. Retention. Stones. Urgency. Urine Discoloration. Urine Odor.
Female Genitalia
Reported:
Menopause.
Denied:
Birth control. Bleeding Between Periods. Change in Periods – Duration. Change in Periods – Flow. Change in Periods – Interval. DES Exposure. Difficult Pregnancy. Discharge. Fertility problems. Hernias. Itching. Lesions. Menstrual pain. Pain on Intercourse. Postmenopausal Bleeding. Recent Pap Smear. Recent Pregnancy. Sexual Problems. Venereal Disease.
Objective
Vital Signs:
Height, Weight, BMI and Measurements
Height
Weight
BMI
Flag
Head
Neck
Waist
5′ 11″
119 (lb)
16.6
Underweight
Physical Exam:
Constitutional
The patient is awake, alert, well developed, well nourished and well groomed.
Age Sex Race:
The patient is a 30 years old female who appears the stated age.
Distress:
This patient is in no acute distress.
Apparent State of Health:
This patient appears to be in generally good health.
Level of Consciousness:
The patient is awake, alert, understands questions and responds appropriately and quickly.
Nutrition:
The patient is well developed and well nourished.
Grooming:
The patient’s is clothing clean and properly fastened. The patient’s hair, nails, teeth and skin are clean and well groomed.
Odor:
The patient’s breath and body odor are normal.
Deformity:
There are no obvious deformities
Psychiatric
Orientation
The patient is oriented to time, place and person.
Memory
Testing for the accuracy of remote and recent memory is within normal limits.
Attention
Attention testing for digit span and serial 7s is within normal limits.
Language
Aphasia evaluation including testing for word comprehension, repetition, naming, reading comprehension and writing were performed and are normal.
Knowledge
The patient’s fund of knowledge: awareness of current events and past history is appropriate for age.
Mood Personality
The patient’s mood is described as sadness The affect is appropriate The patient has the following symptoms of a depressed mood: depressed or irritable mood most of the day nearly every day, fatigue or loss of energy nearly every day, feelings of worthlessness or inappropriate guilt nearly every day, markedly diminished interest or pleasure in almost all activities most of the day nearly every day, insomnia or hypersomnia nearly every day The mood disorder is consistent with major depressive episode
The patient’s social skills are appropriate. The patient does not exhibit any traits consistent with personality disorder.
Speech
The speech rate and quantity is normal and the volume is well modulated. The patient is articulate, coherent; and spontaneous. The flow of words is consistent with normal fluent speech.
Thought Processes
The patient’s thought processes are logical, relevant, organized and coherent.
Associations
The patient’s associations are intact.
Thought Content
There are no obsessive, compulsive, phobic, delusional thoughts. There are no illusions or hallucinations.
Judgment
The patients judgment concerning everyday activities and social situations is good and insight into their condition is appropriate.
MSE : Exam – Mental Status
Appearance
Patient appears to be calm., Patient appears to be friendly., Patient appears to be happy., The patient looks relaxed..
Memory
The patient seems to have immediate memory..
Speech Quality
The patient seems to have normal speech..
Language
The patient expressive language is good.. The patient displays good comprehension language..
Motor Activity
The patients motor activity seems to be normal..
Interpersonal
The patient seems to be friendly..
Behavior
The patients behavior is cooperative..
Stated Mood
The patient seems to be in a okay mood..
Affect
The patient present normal affect..
Psychosis
The patient seems not to be psychotic..
Suicidal
The patient convincingly denies suicidal ideas or intentions..
Homicidal
The patient convincingly denies homicidal ideas or intentions..
I.Q.
Vocabulary and fund of knowledge indicate cognitive functioning in the normal range..
Judgment
Judgement appears intact.
Attention
There are no signs of hyperactive or attention difficulties..
Assessment
Diagnosis:
Comment
Major Depressv Disorder, Recurrent Severe W/o Psych Features
Other Specified Anxiety Disorders
Generalized Anxiety Disorder
Binge Eating Disorder
please this is my last chance to resubmit this assignment. please pay attention to the comment below ——this assignment is a Mental health comprehensive assessment —–your HPI needs more comprehe
History and Physical Date: Chief Complaint: “I am having some trouble catching my breath here lately and my chest is hurting” History of Present Illness: This 94-year-old white female with past history of CHF and HTN presented to the Emergency Department yesterday with complaints of shortness of breath and chest pain. She states that these symptoms have been present for the past 3 days then yesterday began having worsening shortness of breath and increasing chest pain located in the central chest, which she describes as “pressure”. Associated symptom of lower extremity edema. States no alleviating factors. She states she has attempted rest and elevation on extremities, however has had no long term relief of symptoms. She states the pain was 6-7/10 in intensity at the worse and currently 1/10. She was admitted to the hospital where cardiac workup has ensued with negative findings with cardiac enzymes and serial troponin tests. Chest x-ray shows no acute infiltrate. Medications: Crestor 10mg oral every night Flonase 50mcg/inh nasal spray, 2 sprays each nare daily Furosemide 40mg oral BID Micardis 40mg oral daily Potassium Chloride 10mEq oral TID Prilosec 20mg oral daily Relafen 750mg oral daily Xanax 0.5mg oral TID, as needed Zaroxolyn 2.5mg oral daily Zoloft 50mg oral daily Zyrtec 10mg oral daily Amlodipine 5mg oral daily Aspirin 81mg oral daily Allergies: Celebrex – upset stomach Morphine – oversedation Tetanus Toxoid – Rash Past Medical History: Congestive Heart Failure – Controlled until recent issue Hypertension – Controlled Dyslipidemia – Controlled Anxiety Disorder – Controlled Depression – Controlled Diverticulitis – Controlled Seasonal Allergies – Controlled Osteoarthritis – Controlled GERD – Controlled Past Surgical History: Colectomy 1992 (Diverticulitis) Appendectomy 1992 Bilateral Knee Replacement 1995, 1996 Hysterectomy 1984 Sexual/Reproductive History: Heterosexual, widowed, elderly female who denies sexual activity for “many years” since her husband’s death. She has 3 living children and 2 deceased children. Post-menopausal, hysterectomy 1984 Personal/Social History: Denies ever smoking, denies alcohol or illicit drug use. Immunization History: Her immunizations are not up to date regarding tetanus due to allergy to vaccine. She has received an influenza vaccine this year and states received a pneumonia vaccine last year from her PCP. Significant Family History: Father passed away at age 62 from colon cancer. Brother also passed away from colon cancer at age 74. She has no other siblings and her mother died of natural causes. She has a daughter with a significant history of heart disease. Lifestyle: Patient lives with her daughter and is very independent with activities of daily living. She has been widowed for 23 years and just was living alone until last year when she chose to move in with her daughter instead of enter assisted living housing. Her daughter provides her transportation for social events, doctor appointments, and to church activities. She has a primary care physician she visits regularly, however has never been referred to a cardiologist. She states that her husband left her a comfortable living when he passed away and she has no financial issues with affording her basic necessities or her medications. She also has insurance coverage through her late husband and Medicare coverage. She states that she enjoys attending a weekly ladies meeting at her church in which different activities are scheduled each week such as quilting, canning, and volunteer work for the needy in the community. Review of Systems: General: + fatigue, no fever, no chills, +weakness, +decreased activity, no significant weight loss or gains HEENT: No changes in vision or hearing, +wears glasses, no glaucoma, no diplopia, no blurred vision, +bilateral cataracts (last exam 2 months ago), no ear pain, no drainage, no tinnitus, no epitaxis, +allergic rhinitis (mild seasonal) no mouth lesion, no difficulty swallowing, +edentulous (has dentures that are well fitting), no difficulty chewing Neck: No pain, no injury, +limited ROM Breasts: No lesions, no color changes, no history of masses or surgeries Respiratory: No cough, +SOB at rest, no hemoptysis, +orthopnea, +chest discomfort CV: +chest discomfort, no palpitations, no syncope, +peripheral edema, no claudication, + history of murmur, no history of arrhythmias, last cardiac workup 1 year ago. GI: no abdominal pain, no indigestion, no nausea, no vomiting, no diarrhea, +occasional constipation GU: no change in urinary pattern, +nocturia, +stress incontinence, no history of STD, previous hysterectomy, not sexually active since the death of her husband MS: +osteoarthritis, +joint pain, +limited ROM, hx bilateral knee replacements, Psych: +anxiety, +depression, no sleep disturbance, no confusion, no dementia, no delusions, denies suicidal ideation Neuro: no syncopal episodes, no headaches, no dizziness, no paresthesia, no change in memory, no changes in gait pattern (walks with assistive device for safety), no seizure history Integument/Heme/Lymph: no rashes, no lesions, no bruising, no history of skin cancer, no bleeding disorders, no clotting disorders, +history of transfusions with surgery Endocrine: no endocrine symptoms or hormone therapies Allergic/Immunological: +allergic rhinitis (seasonal), no known immune diseases OBJECTIVE DATA Physical Exam: Vital Signs: B/P 111/71, left arm, sitting; Pulse 88 and regular; Resp 28 slightly labored; Pulse Ox 98% on Room Air; Temp 98.7 orally; Wt: 128lbs; Ht: 5’4”; BMI 22 General: Well-groomed elderly female who is alert, oriented X3, appears mildly nervous/uncomfortable. Skin: No rash or open wounds, warm and dry with pink color. Nail beds pink with less than 3 seconds capillary refill. HEENT: PERRLA, normocephalic, moist, pink mucosa, anicteric sclera, pink gums and tongue, slightly pale conjunctiva Chest/Lungs: Bibasilar crackles, no use of accessory muscles, trachea midline, chest expansion is symmetrical, respirations shallow and slightly labored with talking. Cardiac/Peripheral Vascular: Regular rate and rhythm, S1, S2, S3 all muffled by Grade 4/6 pansystolic murmur, no rub or gallop, trace pitting edema in bilateral pedals, pulses +3 all extremities, no carotid bruits, no JVD Abdominal: Non-distended, bowel sounds + x 4 quadrants, no organomegaly, no tenderness, soft GU: Deferred Musculoskeletal: Slight reduced ROM in neck and large joints due to osteoarthritic changes, muscle tone and bulk are adequate Neuro: Cognition intact, answers all questions appropriately, memory is good, oriented to situation, no syncope, no seizures, Cranial nerves grossly intact, DTR’s intact Assessment: Acute Diagnosis: 1. Shortness of Breath-Differential Diagnosis Congestive Heart Failure Exacerbation – Patient has established past medical history of CHF along with bibasilar crackles, shortness of breath, and edema in lower extremities consistent with signs and symptoms of heart failure (Kusumoto, 2012). Mitral Regurgitation – Patient has pansystolic grade 4 murmur with a muffled third heart sound. Elevation in pulmonary capillary pressure leads to the onset of pulmonary edema which is manifested by shortness of breath (Kusumoto, 2012). Aortic Regurgitation: Presence of a systolic murmur along with the symptoms of pulmonary edema indicate aortic regurgitation may be implicated in the cause of shortness of breath (Kusumoto, 2012). 2. Chest Pressure/Pain – Differential Diagnosis Congestive Heart Failure Exacerbation – Patient has established history of CHF along with current signs and symptoms such as bibasilar crackles, chest pressure, shortness of breath, and peripheral edema consistent with diastolic dysfunction. Chest discomfort could be attributed to volume overload and additional respiratory workload (Kusumoto, 2012). Coronary Artery Disease – Acute myocardial infarction has been ruled out with serial cardiac enzymes negative, however may have aortic stenosis which could contribute to chest discomfort along with other symptoms of dyspnea and fatigue (Kusumoto, 2012). Anxiety – Patient has longstanding history of anxiety and depressive disorder in which she takes medication for. Symptoms of anxiety include both chest pain and dyspnea (Kupper, Bonhof, Westerhuis, Widdershoven, & Denollet, 2016). Established Diagnosis: Congestive Heart Failure – possibly decompensated on current treatment regimens Hypertension – controlled with current medications Dyslipidemia – controlled with medication Anxiety/Depression – possibly contributing factor to current signs and symptoms, will need further evaluation Seasonal Allergies – Controlled on current medications Osteoarthritis – Controlled with current medications GERD – Controlled with current medications
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