Assignment: Mental Health Comprehensive Assessment

Assignment: Mental Health Comprehensive Assessment

Assignment: Mental Health Comprehensive Assessment

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

——this assignment is a Mental health comprehensive assessment

—–your HPI needs more comprehensive information.

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

(please explain the differential diagnoses)

—–Needs more information in the MSE section

——please complete the genogram part 2

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

——Zero plagiarism

The Assignment

Part 1: Comprehensive Client Family Assessment

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

Demographic information
Presenting problem
History or present illness
Past psychiatric history
Medical history
Substance use history
Developmental history
Family psychiatric history
Psychosocial history
History of abuse/trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan
Part 2: Family Genogram

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

Learning Resources

Required Readings

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

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

Past Psychiatric History:

Past Diagnosis: eating , disorder, anxiety and depression

Hospitalizations: hospitalized a year ago for depression and eating disorder

History of suicides: none

History of Violence: No

History of self-mutilation: no

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

Psychotherapy: currently at Pathways in Hollywood

Medications trials in the past:lexapro ,lovox,

Current psychotropics: mirtazapine, klonopin ,prochlorperazine

Medication History:

Date

Medication

Sig

#

Refill

Status

06/25/2020

Zoloft 25 mg tablet

1 tablet by mouth daily

30

0

Active

06/25/2020

Remeron 15 mg tablet

1 tablet by mouth nightly

30

0

Active

06/25/2020

prochlorperazine maleate 10 mg tablet

1 tablet by mouth daily

0

Active

Allergies:

patient reproted she is allergic to red colour food or pills

Social History:

Social: Patient is single , no kids

Develpmental: born and raised in Maryland

Alcohol: drinks occassionally

Drug: ; Denies

Abuse: denies

Faith: christian

Occupation: unemployed

Education: High school diploma

Legal: Denies

Family History:

patient denies any family history of mental or medical problems

Review of Systems:

Constitutional

Denied:

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

Eyes

Denied:

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

Respiratory

Denied:

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

Cardiovascular

Denied:

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

Gastrointestinal

Denied:

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

Musculoskeletal

Reported:

joint problems.

Denied:

disturbances of gait or station. muscle strength. tone.

Psychiatric

Reported:

Depression. Nervousness. Mood changes.

Denied:

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

Skin

Reported:

Easting disorder ,scolliosis , seizures

Denied:

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

Neurological

Reported:

seizures disorder

Denied:

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

Endocrine

Denied:

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

Hematologic/Lymph

Denied:

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

Allergic/Immunologic

Denied:

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

Genitourinary

Urinary

Denied:

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

Female Genitalia

Reported:

Menopause.

Denied:

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

Objective

Vital Signs:

Height, Weight, BMI and Measurements

Height

Weight

BMI

Flag

Head

Neck

Waist

5′ 11″

119 (lb)

16.6

Underweight

Physical Exam:

Constitutional

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

Age Sex Race:

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

Distress:

This patient is in no acute distress.

Apparent State of Health:

This patient appears to be in generally good health.

Level of Consciousness:

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

Nutrition:

The patient is well developed and well nourished.

Grooming:

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

Odor:

The patient’s breath and body odor are normal.

Deformity:

There are no obvious deformities

Psychiatric

Orientation

The patient is oriented to time, place and person.

Memory

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

Attention

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

Language

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

Knowledge

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

Mood Personality

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

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

Speech

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

Thought Processes

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

Associations

The patient’s associations are intact.

Thought Content

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

Judgment

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

MSE : Exam – Mental Status

Appearance

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

Memory

The patient seems to have immediate memory..

Speech Quality

The patient seems to have normal speech..

Language

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

Motor Activity

The patients motor activity seems to be normal..

Interpersonal

The patient seems to be friendly..

Behavior

The patients behavior is cooperative..

Stated Mood

The patient seems to be in a okay mood..

Affect

The patient present normal affect..

Psychosis

The patient seems not to be psychotic..

Suicidal

The patient convincingly denies suicidal ideas or intentions..

Homicidal

The patient convincingly denies homicidal ideas or intentions..

I.Q.

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

Judgment

Judgement appears intact.

Attention

There are no signs of hyperactive or attention difficulties..

Assessment

Diagnosis:

Comment

Major Depressv Disorder, Recurrent Severe W/o Psych Features

Other Specified Anxiety Disorders

Generalized Anxiety Disorder

Binge Eating Disorder

ORDER NOW FOR AN EXCELLENT PAPER FROM HEALTH CARE PAPER GURUS: Assignment: Mental Health Comprehensive Assessment

 

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Assignment: Mental Health Comprehensive Assessment

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy

Assignment: Mental Health Comprehensive Assessment

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication

Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.