Sign In
Not register? Register Now!
Essay Available:
Pages:
4 pages/β‰ˆ1100 words
Sources:
Check Instructions
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 17.28
Topic:

Complex Process of Patient Diagnosis and Treatment

Case Study Instructions:

Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
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.
Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
Be succinct in your presentation, and do not exceed 8 minutes. 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 of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain n whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.
PLEASE USE TEMPLATE

Case Study Sample Content Preview:

Week (enter week #): (Enter assignment title)
Student Name
College of Nursing
PRAC 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): The patient, Mrs. S, is a 30-year-old female who presents in the clinic with a complaint of feeling afraid of going out of her house. She indicates that she fears the problem might start to affect her daily activities, and she is seeking help before the condition worsens.
HPI: The patient indicated that for the past three months, she has been forcing herself to go to work. She admits that she feels anxious whenever she is out of the house, and she feels afraid that something might happen when she is away. The patient indicates that she has also been unable to attend social gatherings due to anxiety. Mrs. S also indicated that she has had anxiety problems before, but the condition has become extreme during the last three months to the extent that she fears it might interfere with her daily routines such as going to work. She indicates that she has confidence she can be assisted but needs guidance to overcome her anxiety problems. She is married and lives with her husband and son. Her last menstrual cycle was two weeks ago.
Substance Current Use: The patient does not have a history of substance abuse.
Current Medications: The patient is not currently under any medication but indicates Celexa 40mg was prescribed to her in the past with great success.
Medical History:
Current Medications: no current medications
Allergies: NKA
Reproductive Hx: Menses: Regular 28-day cycles with four-day duration menses; heavy flow first two days and becomes gradually lighter toward the end of menses; sexually active; uses hormonal contraceptive; satisfied with the contraceptive method.
ROS:
• Vital Signs
Weight: 145, T: 97.8 °, P: 85, RR: 18, BP: 118/86. Height: 5’4, BMI: 25.7
• Head: retro-orbital forehead and maxillary sinuses are tenderness to touch
• Eyes: pink conjunctiva and white sclera
• Ears: pearly grey bilaterally
• Throat: No sore throat.
• Nose: nasal mucosa shows bilateral yellow mucus plugs blocking the turbinate’s, swelling noted to nasal bridge, cheeks pharynx mildly erythema, uvula midline, tonsils 1 + bilaterally, lymph nodes non-palpable neck- supple no palpable masses upon palpation
• Respiratory: lung sounds clear bilaterally throughout
• HEART: denies and chest pain or SOB
• ABD- denies any abdominal symptoms upon examination
• Gastrointestinal: BS active in all 4 quadrants. Abdomen soft, non-tender
• Musculoskeletal- denies any back, muscle, or joint pain, indicates neck pain restlessness and feeling fatigued.
• Genitourinary: Bladder is non-distended; no CVA tenderness. Both testes palpable, no masses or lesions, no hernia, no urethral discharge
• Neurological - denies any bowel or bladder incontinence.
• Hematologic: No anemia, bleeding, or bruising.
• Lymphatics: No enlarged nodes.
• Endocrinologic: No reports of sweating, cold, or heat intolerance.
Objective:
Diagnostic Results:
GAD-7 screening. The most common condition that might be aff...
Updated on
Get the Whole Paper!
Not exactly what you need?
Do you need a custom essay? Order right now:
Order

πŸ‘€ Other Visitors are Viewing These APA Case Study Samples: