Essay Available:
Pages:
12 pages/≈3300 words
Sources:
5
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Essay
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 58.32
Topic:
History of Suicide Attempts and/or Self-Injurious Behaviors
Essay Instructions:
*/ You can use any patient with a psychiatric issue, this is for a PMHNP clinical class of Psychotherapy.
For this assignment, students will create a written comprehensive psychiatric evaluation of a patient they have seen in the clinic. Each student will use the Graduate Psychotherapy Note Template Download Graduate Psychotherapy Note Template to create a detailed psychiatric evaluation document. SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The comprehensive psychiatric evaluation is to be written using the attached template below.
S Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) (Links to an external site.) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS); Review of Systems (ROS).
O Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam.
A Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes.
P Plan: Pharmacologic and Nonpharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up.
Other: Incorporate current clinical guidelines NIH Clinical Guidelines (Links to an external site.)or APA Clinical Guidelines (Links to an external site.), research articles, and the role of the PMHNP in your presentation.
Reminder: It is important that you complete this assessment using your critical thinking skills. You are expected to synthesize your clinical assessment, formulate a psychiatric diagnosis, and develop a treatment plan independently. It is not acceptable to document "my preceptor made this diagnosis." An example of the appropriate descriptors of the clinical evaluation is listed below. It is not acceptable to document “within normal limits.”
Submission Instructions:
The paper is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling.
The paper should be formatted per current APA and 8-10 pages in length, excluding the title, abstract and references page. Incorporate a minimum of 5 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work.
Essay Sample Content Preview:
History of Suicide Attempts and/or Self-Injurious Behaviors
Patient Initials: L.R. Gender: M/F/Transgender Female Age: 25 Race: American Ethnicity: Caucasian
Reason for Seeking Health Care: "I have an intense fear of getting fat, but my family insisted that I looked weak and malnourished, so I had to go here."
HPI: Five months prior to consultation, the patient joined local pageantry, and she was told that she needed to lose weight to have the bikini body requirement. Hence, the patient started to eat only approximately 500 to 1000 kilocalories daily and did not eat carbohydrate- and fat-rich foods. The patient also engaged in extreme workouts that lasted for 5 hours daily and practiced this seven times a week. The patient lost 15 kilograms in three weeks, which was in time for her pageant. She eventually won the crown and was hailed the best swimsuit attire.
Four months prior to consultation, the patient continued her diet and extreme workouts. However, due to her fear of gaining weight, she reduced her calorie intake to 500 to 700 daily. Her friends expressed their concern over her crash diet but did not listen to them because she thought she was still fat, despite her family and friends telling her that her body was significant enough for any competition. She continued this lifestyle until she lost another 10 kilograms in just a month.
Three months prior to consultation, the patient started to eat less than 200 kilocalories during weekdays and only drank water during weekends. She states that she feels hungry most of the time but refuses to eat, even when her mother cooks her favorite food, because she does not want to get fat. She wanted to maintain her body and reduce her weight even more. Her parents expressed their concern over her drastic weight reduction because, according to them, she looked "pale and thin like a corpse." However, the patient did not believe them and told them that the diet was still insufficient.
Two months prior to consultation, the patient almost stopped eating for four consecutive days, only having water to fill her stomach. After the fourth day, the patient was brought to the emergency room for loss of consciousness. The attending physician stated that the patient suffered from non-diabetic hypoglycemia and iron deficiency anemia and opted to hospitalize the patient for total parenteral nutrition due to the patient's refusal to eat and blood transfusion. She was then referred to the psychiatry department, but the patient refused to follow the management. She was then diagnosed with anorexia nervosa, restricting type, moderate, and was provided psychosocial support and psychotherapy, for which the patient did not comply after being discharged. The patient did not think that the condition was severe and claimed that she had seen many models even thinner than her and wanted to achieve such an appearance.
Interim history revealed the persistence of the patient's mindset and lifestyle and the refusal to avail of the outpatient treatment for anorexia.
A few hours prior to consultation, the patient was forcedly brought by her parents to the psychiatry department of our institution due to her persistent lifestyle. The parents claimed that the patient did not believe that her body was already thinner than usual and that she looked sick. The patient claimed no instances where she had binge-eating tendencies, had excessive use of laxatives, or practiced forced vomiting after a meal. The patient claimed that she only refused to eat and wanted to continue her intense exercise sessions.
SI/HI: The patient denies any suicidal or homicidal ideations.
Sleep: The patient usually sleeps at 11:00 PM because she works out until 9:00 PM and wakes up at 5:00 AM for quick jogging in their neighborhood. Her sleep was continuous with no noted disturbances. Appetite: The patient had poor fluid and oral intake and refused to eat anything most of the time. She only takes in a spoon of food when she eats and replenishes her nutritional needs using water only.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient denies allergies to food, drugs, latex, herbal medicines, and the environment.Current perception of Health: Good
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
March 22, 2022
______
Anorexia nervosa, restricting type, moderate; non-diabetic hypoglycemia, secondary, iron deficiency anemia, secondary
Seven days
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
None
Not applicable
Not applicable
Not applicable
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
None
Not applicable
Not applicable
Not applicable
History of suicide attempts and/or self-injurious behaviors: The patient and the parents denied any history of suicidal or self-injurious behavior.
Past Medical History
* Major/Chronic Illnesses: Anorexia nervosa, restricting type, moderate, iron deficiency anemia, secondary (Active)
* Trauma/Injury: None
* Hospitalizations: The patient was hospitalized on March 22, 2022, for seven days due to anorexia nervosa, restricting type, moderate, with non-diabetic hypoglycemia, secondary, and iron deficiency anemia, secondary.
Past Surgical History: None
Current psychotropic medications: The following are the patient's medications despite being non-compliant:
1 Fluoxetine HCl 20mg/capsule. Take one capsule orally once a day before or after breakfast for 30 days to treat anorexia nervosa.
2 Olanzapine 2.5mg/tablet. Take one tablet orally once a day at bedtime for four weeks.
Current prescription medications:
1 Ferrous sulfate 325mg/tablet (60mg elemental iron). Take one tablet orally three times a day for two months, then for re-evaluation.
OTC/Nutritionals/Herbal/Complementary therapy: None
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
None
Not applicable
Not applicable
Not applicable
The patient denies using alcohol, cigarettes, e-vape, caffeine, and illicit drugs such as marijuana, cocaine, and methamphetamine.
Family Psychiatric History: There is no known family history of mood disorders, including bipolar and major depressive disorder, genetic disorders, or history of suicidal attempts or ideation in the patient's family, including her mother, father, two older brothers, and two younger sisters.
Social History
Lives: Family house, two floors, with one flight of stairs.
Marital Status: Single
Education: Bachelor of Arts in English
Employment Status: Unemployed Current/Previous occupation type: Previously worked as a part-time model for a local magazine and photography studio and as a part-time English tutor for primary school students.
Exposure to: Smoke: None ETOH: The patient was a previous alcoholic beverage drinker but stopped since she started dieting five months ago. Recreational Drug Use: None.
Sexual Orientation: Homosexual Sexual Activity: Inactive Contraception Use: None
Family Composition: Family/Mother/Father/Alone: The patient currently lives with her parents, who are happily married. She has two older brothers who work in another locality and two younger sisters who live with her in their parents' house.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient was born in San Francisco, California. Her childhood was filled with happy moments. She does not have any pending or active legal cases. She currently lives with her parents. Her hobbies include doing long hours of exercise and playing volleyball. She denies any history of abuse, trauma, accidents, or exposure to any form of violence. She has a small social network. She is single, was not previously married, and did not have a common-law husband or live-in partner.
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia: No laboratory or diagnostic tests were reviewed.
Exposures: The patient does not have any exposure to chemical hazards or radiation.
Immunization H.X.: The patient claims to have complete immunization during her childhood but failed to provide her baby book. She received three doses of the COVID-19 vaccine (Pfizer).
Review of Systems (at least three areas per system)
General: admits to weight loss and occasional fainting spells due to hypoglycemic episodes; denies fever, loss of appetite
HEENT: denies headache, eye pain, blurring or doubling of vision, deafness, tinnitus, nosebleeds, loss of smell, hoarseness of voice, difficulty swallowing, loss of taste, and dental problems
Neck: Denies cervical lymph node tenderness, globus sensation, and stiff neck
Lungs: Denies difficulty of breathing, coughing, and wheezing
Cardiovascular: Admits easy fatigability and occasional palpitations; denies chest pain, bipedal edema, or cyanosis
G.I.: Admits to anorexia and constipation; denies nausea, vomiting, bloody stools, and diarrhea
GU: Denies dysuria, changes in urinary frequency, and dribbling
Neuro: Denies changes in sensorium, tingling, and sudden weakness
Musculoskeletal: Denies limitation of motion, muscle pain, or muscle weakness
Activity & Exercise: Admits to exercise for long hours (~five hours per day, seven times a week) with the concomitant play sports, including voll...
Patient Initials: L.R. Gender: M/F/Transgender Female Age: 25 Race: American Ethnicity: Caucasian
Reason for Seeking Health Care: "I have an intense fear of getting fat, but my family insisted that I looked weak and malnourished, so I had to go here."
HPI: Five months prior to consultation, the patient joined local pageantry, and she was told that she needed to lose weight to have the bikini body requirement. Hence, the patient started to eat only approximately 500 to 1000 kilocalories daily and did not eat carbohydrate- and fat-rich foods. The patient also engaged in extreme workouts that lasted for 5 hours daily and practiced this seven times a week. The patient lost 15 kilograms in three weeks, which was in time for her pageant. She eventually won the crown and was hailed the best swimsuit attire.
Four months prior to consultation, the patient continued her diet and extreme workouts. However, due to her fear of gaining weight, she reduced her calorie intake to 500 to 700 daily. Her friends expressed their concern over her crash diet but did not listen to them because she thought she was still fat, despite her family and friends telling her that her body was significant enough for any competition. She continued this lifestyle until she lost another 10 kilograms in just a month.
Three months prior to consultation, the patient started to eat less than 200 kilocalories during weekdays and only drank water during weekends. She states that she feels hungry most of the time but refuses to eat, even when her mother cooks her favorite food, because she does not want to get fat. She wanted to maintain her body and reduce her weight even more. Her parents expressed their concern over her drastic weight reduction because, according to them, she looked "pale and thin like a corpse." However, the patient did not believe them and told them that the diet was still insufficient.
Two months prior to consultation, the patient almost stopped eating for four consecutive days, only having water to fill her stomach. After the fourth day, the patient was brought to the emergency room for loss of consciousness. The attending physician stated that the patient suffered from non-diabetic hypoglycemia and iron deficiency anemia and opted to hospitalize the patient for total parenteral nutrition due to the patient's refusal to eat and blood transfusion. She was then referred to the psychiatry department, but the patient refused to follow the management. She was then diagnosed with anorexia nervosa, restricting type, moderate, and was provided psychosocial support and psychotherapy, for which the patient did not comply after being discharged. The patient did not think that the condition was severe and claimed that she had seen many models even thinner than her and wanted to achieve such an appearance.
Interim history revealed the persistence of the patient's mindset and lifestyle and the refusal to avail of the outpatient treatment for anorexia.
A few hours prior to consultation, the patient was forcedly brought by her parents to the psychiatry department of our institution due to her persistent lifestyle. The parents claimed that the patient did not believe that her body was already thinner than usual and that she looked sick. The patient claimed no instances where she had binge-eating tendencies, had excessive use of laxatives, or practiced forced vomiting after a meal. The patient claimed that she only refused to eat and wanted to continue her intense exercise sessions.
SI/HI: The patient denies any suicidal or homicidal ideations.
Sleep: The patient usually sleeps at 11:00 PM because she works out until 9:00 PM and wakes up at 5:00 AM for quick jogging in their neighborhood. Her sleep was continuous with no noted disturbances. Appetite: The patient had poor fluid and oral intake and refused to eat anything most of the time. She only takes in a spoon of food when she eats and replenishes her nutritional needs using water only.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient denies allergies to food, drugs, latex, herbal medicines, and the environment.Current perception of Health: Good
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of Stay
March 22, 2022
______
Anorexia nervosa, restricting type, moderate; non-diabetic hypoglycemia, secondary, iron deficiency anemia, secondary
Seven days
Outpatient psychiatric treatment:
Date
Hospital
Diagnoses
Length of Stay
None
Not applicable
Not applicable
Not applicable
Detox/Inpatient substance treatment:
Date
Hospital
Diagnoses
Length of Stay
None
Not applicable
Not applicable
Not applicable
History of suicide attempts and/or self-injurious behaviors: The patient and the parents denied any history of suicidal or self-injurious behavior.
Past Medical History
* Major/Chronic Illnesses: Anorexia nervosa, restricting type, moderate, iron deficiency anemia, secondary (Active)
* Trauma/Injury: None
* Hospitalizations: The patient was hospitalized on March 22, 2022, for seven days due to anorexia nervosa, restricting type, moderate, with non-diabetic hypoglycemia, secondary, and iron deficiency anemia, secondary.
Past Surgical History: None
Current psychotropic medications: The following are the patient's medications despite being non-compliant:
1 Fluoxetine HCl 20mg/capsule. Take one capsule orally once a day before or after breakfast for 30 days to treat anorexia nervosa.
2 Olanzapine 2.5mg/tablet. Take one tablet orally once a day at bedtime for four weeks.
Current prescription medications:
1 Ferrous sulfate 325mg/tablet (60mg elemental iron). Take one tablet orally three times a day for two months, then for re-evaluation.
OTC/Nutritionals/Herbal/Complementary therapy: None
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
None
Not applicable
Not applicable
Not applicable
The patient denies using alcohol, cigarettes, e-vape, caffeine, and illicit drugs such as marijuana, cocaine, and methamphetamine.
Family Psychiatric History: There is no known family history of mood disorders, including bipolar and major depressive disorder, genetic disorders, or history of suicidal attempts or ideation in the patient's family, including her mother, father, two older brothers, and two younger sisters.
Social History
Lives: Family house, two floors, with one flight of stairs.
Marital Status: Single
Education: Bachelor of Arts in English
Employment Status: Unemployed Current/Previous occupation type: Previously worked as a part-time model for a local magazine and photography studio and as a part-time English tutor for primary school students.
Exposure to: Smoke: None ETOH: The patient was a previous alcoholic beverage drinker but stopped since she started dieting five months ago. Recreational Drug Use: None.
Sexual Orientation: Homosexual Sexual Activity: Inactive Contraception Use: None
Family Composition: Family/Mother/Father/Alone: The patient currently lives with her parents, who are happily married. She has two older brothers who work in another locality and two younger sisters who live with her in their parents' house.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient was born in San Francisco, California. Her childhood was filled with happy moments. She does not have any pending or active legal cases. She currently lives with her parents. Her hobbies include doing long hours of exercise and playing volleyball. She denies any history of abuse, trauma, accidents, or exposure to any form of violence. She has a small social network. She is single, was not previously married, and did not have a common-law husband or live-in partner.
Health Maintenance
Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia: No laboratory or diagnostic tests were reviewed.
Exposures: The patient does not have any exposure to chemical hazards or radiation.
Immunization H.X.: The patient claims to have complete immunization during her childhood but failed to provide her baby book. She received three doses of the COVID-19 vaccine (Pfizer).
Review of Systems (at least three areas per system)
General: admits to weight loss and occasional fainting spells due to hypoglycemic episodes; denies fever, loss of appetite
HEENT: denies headache, eye pain, blurring or doubling of vision, deafness, tinnitus, nosebleeds, loss of smell, hoarseness of voice, difficulty swallowing, loss of taste, and dental problems
Neck: Denies cervical lymph node tenderness, globus sensation, and stiff neck
Lungs: Denies difficulty of breathing, coughing, and wheezing
Cardiovascular: Admits easy fatigability and occasional palpitations; denies chest pain, bipedal edema, or cyanosis
G.I.: Admits to anorexia and constipation; denies nausea, vomiting, bloody stools, and diarrhea
GU: Denies dysuria, changes in urinary frequency, and dribbling
Neuro: Denies changes in sensorium, tingling, and sudden weakness
Musculoskeletal: Denies limitation of motion, muscle pain, or muscle weakness
Activity & Exercise: Admits to exercise for long hours (~five hours per day, seven times a week) with the concomitant play sports, including voll...
Get the Whole Paper!
Not exactly what you need?
Do you need a custom essay? Order right now: