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.
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—–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
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).
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
Zoloft 25 mg tablet
1 tablet by mouth daily
Remeron 15 mg tablet
1 tablet by mouth nightly
prochlorperazine maleate 10 mg tablet
1 tablet by mouth daily
patient reproted she is allergic to red colour food or pills
Social: Patient is single , no kids
Develpmental: born and raised in Maryland
Alcohol: drinks occassionally
Drug: ; Denies
Education: High school diploma
patient denies any family history of mental or medical problems
Review of Systems:
Chills. Decline in Health. Fatigue. Fever. Malaise. Other abnormal constitutional symptoms. Weakness. Weight Gain. Weight loss.
Blurry Vision. Cataracts. Discharge. Double Vision. Excessive tearing. Eye Pain. Eyeglass Use. Glaucoma. Infections. Pain with Light. Recent Injury. Redness. Unusual sensations. Vision Loss.
Asthma. Bronchitis. Cough. Coughing Blood. Pain. Pleurisy. Positive TB Test. Recent Chest X-Ray. Short of Breath. Sputum. Tuberculosis. Wheezing.
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.
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.
disturbances of gait or station. muscle strength. tone.
Depression. Nervousness. Mood changes.
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.
Easting disorder ,scolliosis , seizures
Dryness. Eczema. Hair dye. Hair texture change. Hives. Itching. Lumps. Mole Increased Size. nail appearance change. nail texture change. Rashes. Skin Color Change.
Blackouts. Burning. Dizziness. Fainting. Head Injury. Headaches. Loss of consciousness. Memory loss. Numbness. Paralysis. Speech disorders. Strokes. Tingling. Tremors. Unsteady gait.
Cold intolerance. Excessive Urination. Fatigue. Goiter. Heat intolerance. Increased Thirst. Neck Pain. Sweats. Thyroid Trouble. Weakness. Weight gain. Weight loss.
Anemia. Bleeding easily. Blood clots. Easy bruisability. Lumps. Radiation Exposure. Swollen glands. Transfusion reaction.
Coughing. Coughing with Exercise. Hives. Itchy Eyes. Itchy Nose. Recurrent infections. Runny Nose. Sneezing. Stuffy Nose. Watery Eyes. Wheezing. Wheezing with exercise.
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.
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.
Height, Weight, BMI and Measurements
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.
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.
The patient is well developed and well nourished.
The patient’s is clothing clean and properly fastened. The patient’s hair, nails, teeth and skin are clean and well groomed.
The patient’s breath and body odor are normal.
There are no obvious deformities
The patient is oriented to time, place and person.
Testing for the accuracy of remote and recent memory is within normal limits.
Attention testing for digit span and serial 7s is within normal limits.
Aphasia evaluation including testing for word comprehension, repetition, naming, reading comprehension and writing were performed and are normal.
The patient’s fund of knowledge: awareness of current events and past history is appropriate for age.
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.
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.
The patient’s thought processes are logical, relevant, organized and coherent.
The patient’s associations are intact.
There are no obsessive, compulsive, phobic, delusional thoughts. There are no illusions or hallucinations.
The patients judgment concerning everyday activities and social situations is good and insight into their condition is appropriate.
MSE : Exam – Mental Status
Patient appears to be calm., Patient appears to be friendly., Patient appears to be happy., The patient looks relaxed..
The patient seems to have immediate memory..
The patient seems to have normal speech..
The patient expressive language is good.. The patient displays good comprehension language..
The patients motor activity seems to be normal..
The patient seems to be friendly..
The patients behavior is cooperative..
The patient seems to be in a okay mood..
The patient present normal affect..
The patient seems not to be psychotic..
The patient convincingly denies suicidal ideas or intentions..
The patient convincingly denies homicidal ideas or intentions..
Vocabulary and fund of knowledge indicate cognitive functioning in the normal range..
Judgement appears intact.
There are no signs of hyperactive or attention difficulties..
Major Depressv Disorder, Recurrent Severe W/o Psych Features
Other Specified Anxiety Disorders
Generalized Anxiety Disorder
Binge Eating Disorder