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SOLVED10

summary a mental health status comprehensive by this information

 

1. Age (1): 71 2. Ethnicity (1): Hispanic 3. Resides in what City/Town/State (Do not write the address here) (1): Campwood, Tx 4. Reason for Referral/Reason for Visit/Chief Complaint (1): Schizophrenia 5. History of the Present Illness (2): • Primary Schizophrenia, unspecified • Depression, unspecified • Anxiety disorder, unspecified • Altered mental status, unspecified. • Cognitive Communication Deficit • Type 2 Diabetes Mellitus w/ Hyperglycemia • Other seizure • Chronic Pain Syndrome • Essential (primary) Hypertension • Muscle wasting and atrophy, not elsewhere classified unspecified. • Aphasia 6. Past Psychiatric History (2): • Schizophrenia, unspecified • Depression, unspecified • Anxiety disorder, unspecified • Altered mental status, unspecified. • Cognitive Communication Deficit 7. Past Medical History (5): • Primary Schizophrenia, unspecified • Depression, unspecified • Anxiety disorder, unspecified • Altered mental status, unspecified. • Cognitive Communication Deficit • Type 2 Diabetes Mellitus w/ Hyperglycemia • Other seizure • Chronic Pain Syndrome • Essential (primary) Hypertension • Muscle wasting and atrophy, not elsewhere classified unspecified. • Aphasia 8. Current Medications (List all including psychopharmacological, non-psychopharmacological, vitamins, homeopathics, herbals, supplements, alternatives, investigational) (10): • All current medications on medications profile 9. Substance Use History (5): • N/A 10. Current/Recent Laboratory Findings (10): • A1C Q3 months (Oct, Jan, April, July) everyday shift every 3 month(s) starting on 1st for 3 day(s). • CMP, CBC w/ Diff, LIPID, Liver, Q 12 months (OCTS) every days shift every 12 month(s) starting on 1st for 3 day(s). • Keppa Q6 months (OCT, April) every day shift every 6 month(s) starting on the 1st for 3 day(s). 11. Imaging Findings (if any) (1): • N/A 12. Family History (Use a genogram if possible) (5): • Divorced • Numbers to contact. • Brother • Daughter • Grand daughter 13. Social (2): Client’s routine has changed, due to the Cedar Hill staff. He would’ve been sleeping all day, but they assisted him with his daily routine and spent time near the nursing station with other residents. 14. Developmental/Academic/Work History (2): The client expressed difficulty in recollection, describing their mind as going “boom”. Despite my effects to assist in recollection, he struggled. However, he mentioned a past interest in cars, indicating a potential mechanical inclination through reading and working on cars with his son. 15. Mental Status Exam (Complete Mental Status Exam – see the Mental Status Exam Tools, not the Mini-Mental) (20): 16. Patient Strengths (5): Client is A&OX1 and speaks clearly. 17. Weaknesses (5): The client exhibits a weakness in being non-alert and non-oriented to place, time, and situation. He needs assistance for ADL’s due to being incontinent and has trouble in memory recall, contributing to their overall health. 18. Summary (5): 19. DSM-IV-TR Diagnosis (from patient’s chart) Fill out if available in chart- Axis I: F20.9 Fill out if available in chart- Axis I: F20.9 Schizophrenia, unspecified. Axis I: F 32.A Depression, unspecified. Axis II: F 41.9 anxiety disorder, unspecified. Axis III: R41.82 Altered Mental status, unspecified. Axis IV: R41.841 Cognitive Communication Deficit Axis V: N/A What do you call your problem – What name does it have? (1) Client expressed he doesn’t know about his illness/reason being here. What do you think caused your problem? (1) The client reported experiencing memory problems, potentially attributed to a car accident or a head injury from an external impact. Why do you think it started when it did? (1) The client does not remember. What does your sickness (illness) do to you? (1) The client continues to struggle with memories. How does your sickness (illness) work? (1) The client described moments when their mind feels like it “goes boom,” making it challenging to connect the dots to their memories. tH How severe is it? (1) The client experiences a lack of awareness regarding place, time, and situation each morning. As a result, he requires assistance with his ADL. This indicates a level of cognitive impairment that affects their orientation and ability to independently navigate their surrounding and daily routines. Will it have a short or a long course? (1) Long term due to impairment cognitive 1. What do you fear most about your sickness (illness)? (1) The client expressed, if staff members not willing to help him. I reassured the client, we’re here to help him. 2. What are the chief problems your sickness (illness) has caused for you? (2) I would say his impairment cognitive 3. What kinds of treatments do you think you should receive? (1) The client expressed the able to have a conversation about his concerns. He desires to keep thing moving and willing get through the day. He wants to be involved in activities as well. What are the most important results you hope to receive (achieve) from your treatment? (1) The client expressed a desire to keep things moving and is willing to engage in conversation with other. I would say, he want to be noticed.
use this as example

Image transcription text

The client is a white 74-year-old male who appears
stated age. He is ambulatory with a slow 2ady gait,
the client will acknowledge your arrival … Show more
SCIENCE
HEALTH SCIENCE
NURSING
RNSG 1161

 
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