i am replying to a peer’s post on writing treatment notes

NU-664C-02-23PCS3 FamilyPsychiatric Ment.Hlth I

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  4. Week 6: DSM Case Formulation
  5. Week 6 Discussion 1: Writing Treatment Notes

Week 6 Discussion 1: Writing Treatment Notes

Done: Make forum posts: 1

Value: 100 points

Due: In an effort to facilitate scholarly discourse, create your initial post by Day 4, and reply to at least two of your classmates, on two separate days, by Day 7.

Grading Category: Discussions

Note: In this type of discussion, you will not see the responses of your classmates until after you have posted your own response to the question below.

Initial Post

Watch the following video:

Psychiatric Interview and Mental Status Exam (25:06 minutes)

Psychiatric Interview and Mental Status Exam Video Transcript

  1. Using the readings and references, write a complete SOAP note for this patient in the proper format.
  2. Post the SOAP note to this discussion board for your peer review.
  3. Your post should include a subjective and objective section with correct patient information, an explanation of differential diagnoses, and a comprehensive treatment plan which incorporates both psychosocial interventions as well as a medication plan, if indicated, with collateral information and patient education.
  4. Use appropriate scholarly references and APA format.
  5. Use the SOAP note template found in the Week 6: Learning Materials for your submission.

Replies

Reply to at least two of your classmates. In your reply posts, critique the plan by answering the following questions:

  • Do you agree or disagree with the plan?
  • Is anything missing from the plan?
  • Compare your peer’s plan to yours. What are the advantages and disadvantages of each?
  • Your response should include evidence of review of the course material through proper citations using APA format.

Pick out an idea from your peers’ initial post that you find most interesting and tell how you will use this information in practice.

Please refer to the Grading Rubric for details on how this activity will be graded. The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations.

Posting to the Discussion Forum

  1. Select the appropriate Thread.
  2. Select Reply.
  3. Create your post.
  4. Select Post to Forum.   

 

 

Re: Week 6 Discussion 1: Writing Treatment Notes

by Abbey Johnson – Wednesday, 7 June 2023, 9:38 PM

Abbey JohnsonRegis College: NU664Professor: Professor Megan HawkPatient Name: CoryDOB: unknown, but patient reports he is 16 years old.INSURANCE: BCBSSex: MaleCHIEF Complaint:Patient (Cody) is a new patient presenting to evaluation. Patient’s mother is concern about patient grades in school. States “not doing well in school” and his grades are getting worse in school.SUBJECTIVE:History of Present Illness:Patient presents for initial visit. He is a 16 Caucasian male reports difficulty concentrating in class. Patient tends to veer off course in class He admits to misses deadlines in class and forgetting to bring his textbooks home. He reports not doing his homework or forgetting to do the homework, not studying and studying sometimes. He admits to “not paying attention”. Patient states he “just can’t concentrate”. Patient report he is quite impulsive and regularly cancels plans with his friends at the last minute. Patient is unable to participate in sports as a result of his grades in school. Report he feels depressed and sad about not being able to participate in sports. According to patient, he likes playing sports (basketball).Medical History: No previous medical history discussed. No hospitalization or surgical history.Surgical History: No surgeryFood/Environmental Allergies: “bees”Family History: unknownDrug Allergies: NKDA.Social History: Sophomore in High School. He is a student. He likes Woodshop and love sports. He is Unemployed, but during summer he and his friends go and shovel people’s driveways and stuff in the neighborhood or rake leaves and stuff. Lives with family-parents (mother and Father); Siblings: 1 sister (in college). No pets. Married; denied. Likes to play video games, call friends to hang out.Social Support: He have lots of friends at school, mostly out of his class (2-3 friends. Interested Support; Questionable Support; Some Limited Support; No family/support.Tobacco Use History: unknown Substance Abuse History: unknown; Alcohol Use: unknownFamily History: Strong family support (mother and father) Family Psychiatric History: Unknown.Previous Counselor(s)/Psychiatrist: Denied; Past Psychiatric History: UnkownPrevious Medication History: Unknown.Current Psychosis (Do you see or hear things others do not see or hear?): Denies;Previous Psychosis (Have you ever seen or heard things others didn’t see or hear?): Unknown.Past Psychiatric Hospitalization: Denies; Previous Suicide Attempt(s)/Thought(s): Denies.History of Jail/Prison/Incarceration/Legal Troubles: unknown; Past Trauma: Denies.Sleep Disturbances: “trouble falling asleep”, “sometimes it takes me a little bit to fall asleep”. None; Trouble falling asleep; Trouble staying asleep; Sleeping too much; Previous Seizure Activity: Denies.REVIEW OF SYSTEM:Constitutional: No concerns; Denies fever or chills;Respiratory: No concerns; Denies coughing, shortness of breath, asthma, or allergic rhinitis; Cardiovascular: No concerns; Denies chest pains, racing heart, fainting, or lightheadedness; GI: Normal elimination; Denies nausea, vomiting, diarrhea, constipation, heartburn, or abd pain; GU: Normal urination; Denies frequency, urgency, itching, burning, or nocturia/nocturnal enuresis;Musculoskeletal: No concerns; Denies joint or muscle pain or discomfort;Neurological: No concerns; Denies headache, dizziness, numbness, or tingling;Endocrine: No concerns; Denies fatigue, weight loss or weight gain, loss of appetite or overeating;Skin: No concerns; Denies excessive sweating, dryness, rashes, abrasions, discoloration, lesions, or lacerations; Psycho: difficulty concentrating, and impulsiveHematologic: No concerns; Denies bruises, excessive bleeding, purple spots;Immunologic: No concerns; Denies any infectionsOBJECTIVE:VITAL SIGNS: Ht:;unknownWt: unknown, 6’0BMI: ; unknown 250 lbs (65.77 Kg)MENTAL STATUS EXAM:General Appearance: Well groomed; dressed appropriate for weather; good posture.Appears older than stated age; appears to be overweight. No EPS or tardive dyskinesia symptoms observed.Attitude: Calm, relaxed and cooperative with PMHNP Student;Speech: Fluent and normal rate, volume and tone.Mood (Client Reported): calm, no agitation, Euphoric; Affect (Visible Mood): Euthymic and congruent with Mood; Thought Processes (Organized/Expressed): Normal and Organized; Goal oriented; Linear; Denied suicidal or homicidal ideation. No report of acute psychosis;Thought Content: Normal;Associations: Well-related;Perception: Denies audio/visual hallucinations. No report of paranoia or delusion.Cognition: inattentive and impulsiveLevel of Consciousness: Alert;Orientation: alert x person, place, time, and situationDecision Making/Impulse Control: Intact;Concentration/Attention Span/Calculation: Fair, Attention span: Fair.Memory: IntactJudgment: Good as evidenced by ability to plan for future events;Insight: Good as evidenced by understanding of illness and need to participate in treatment.MSE: normal, Cory was able to the test correctly and repeat three syllables. He was able to recall the words when asked to repeat it.PHQ-9 Depression Screening: unknownRisk Assessment: Denied SI/HI, SIB and V/AH.GAD 7-Item Scale: unknownLabs: unknownASSESSMENT:ADHD (attention deficit hyperactivity disorderDifferential Diagnosis:1. Conduct Disorder2. Developmental Disorders (autism spectrum disorder)3. Learning Disorders4. ADHDADHD is a chronic neurodevelopmental disorder that involves persistent inattention and or hyperactivity and impulsivity that may interferes with development. Patient symptoms meets the DSM 5 criteria for ADHD. Patient was assessed at school and at home. He meets majority of the criteria for ADHD. Patient does not pay close attention to details and difficulty with attention. He is forgetful and struggle with organization. Patient is impulsive and cancels plans with friends. (American Psychological Association, 2020).TREATMENT PLAN:Medication Management:Strattera (Atomoxetine): Start at 40 mg daily (AM) X 3 days and gradually increase to a maximum dose of 100mg daily. Strattera is a selective inhibits norepinephrine reuptake. I chose this medication it is the least additive and helps with reduction in attention and other cognitive symptoms (epocrates, 2023). Strattera also helps with anxiety. It appears the Cody may have some unlined anxiety and inattentiveness. Strattera is a second line treatment for ADHD. The first line treatment for ADHD, Adderall is very additive and abused. FDA announced a shortage of this medication (Epocrates, 2023. It is important to inform patient and of the potential side effects of the medication such as sedation, fatigue, decreased appetite and elevated blood pressure, psychosis, mania aggressive behavior, depression, suicidality thoughts, hypersensitivity, etc. Inform consent should be obtain from the patient parents. (Stahl, 2017). Stress the importance of medication adherence with patient and mother. Patient and mother made informed decision to start medication.Risk Assessment: Patient is at low risk of danger to self and other. Patient and parents advised if symptoms worsen to go to the emergency room or urgent care or call 911.Sleep Hygiene: Encourage and discussed good sleeping habits. Encourage patient to start bedtime routine and sleep schedule.Psychotherapy and psychoeducation504 plans (helps provide the type of accommodation he might need)IEP (Personalized Education Plan). This can be used to provide individual support.Behavioral TherapyCognitive Behavior TherapyReferral: Possible to Neuropsychological testing to rule out learning disability and supportive groups/advocacy organizationsOther test: Labs: CBC, TSH, CMP, Vitals, Height, weight, BMI, EKG, ADHD screening measures (Vanderbilt-ADHD) and child behavior checklist, lead exposure,Complimentary Therapies: Vitamins or dietary supplementsFollow up in 4 weeks.Reference:American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). American Psychological Association. ISBN: 978-1433832161Epocrates. (2023). Epocrates medical references (Version 23.5.2) [Mobile app]UMass Nursing 690M. (2016). Psychiatric Interview and Mental Status Exam: Georgianna Shea, Case Study #2Stahl, S. M., & Grady, M. M. (2017). Stahl’s Essential Psychopharmacology: Prescriber’s Guide. Cambridge university press.

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