NR 603 Week 6 Mental Health Final Treatment Plan-Analysis - Part 2
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$20.00
| Term | Summer 2020 |
| Institution | NR 603 Advanced Clinical Diagnosis and Practice Across the Lifespan |
| Contributor | Shanzay |
After further review of this patient being seen in the emergency department for a traumatic incident, I agree with the following subject information, objective information, and treatment plan.
Patient: C.U.
Patient Demographics:
Age: 79 y.o
Sex: female
Race: African American
Subject:
CC: distressed, delusional, confused, extreme fear and anxiety
History: 79-year-old female has been living at her independent living facility since 2010. She is fully functional and independent. She provided care for five years for her husband who recently passed away six months ago. Her only relative is a daughter who talks with her about once a month. Two days ago, her home was broken into, and she was raped and robbed. The housekeeper found her laying on the floor. She was down for two days and was taken to a local hospital. Here, she is distressed, delusional, and is reported to be very emotionally distraught. There are no signs of broken bones or rhabdomyolysis
SHx:
Marital Status: widowed
Children: one daughter
Occupation: retired school secretary
Living Quarters: independent living facility
Tobacco use: Denies
Alcohol use: Denies
Illicit drug use: Denies
PMHx: Chronic conditions are pernicious anemia, osteoarthritis, and urinary incontinence
PSHx: hysterectomy
Allergies: penicillin
Current Medications:
Multivitamin one-a-day for women
Cyanocobalamin (vitamin B12) 1000mcg
Capsaicin topical cream 0.075%
ROS:
Systemic: Denies fever, chills, or recent weight gain
HEENT: Denies headaches, facial pain, or sinus pain. No earache, nasal discharge, nasal passage blockage, or sore throat.
Cardiovascular: No chest pain, palpitation, no awakening with shortness of breath, orthopnea, or limb swelling.
Pulmonary: Denies wheezing, dyspnea on exertion, shortness of breath, or chest congestion. Mother noted snoring.
Gastrointestinal: Denies yellow skin or eyes, a decrease in appetite, difficulty swallowing, heartburn, pain on swallowing, vomiting blood, or melena.
Genitourinary: Denies polyuria, dysuria, incontinence, flank pain, and hematuria
Musculoskeletal: Denies muscle aches, limb pain, joint pain, or joint swelling.
Neurological: confused by the situation, denies syncope, vertigo, dizziness, sensory disturbances, motor disturbances, gait abnormality, or speech difficulties.
Psychological: reports excessive worry, extreme fear and anxiety and is emotionally distraught.
Skin: Denies redness of the skin, itching, rash, lesions, or nail abnormalities........ continue
| Instituition / Term | |
| Term | Summer 2020 |
| Institution | NR 603 Advanced Clinical Diagnosis and Practice Across the Lifespan |
| Contributor | Shanzay |
