Comprehensive Mental Health Analysis
Comprehensive Mental Well being Assessment 2
Derek T. Booth
Indianapolis University Purdue University Indiana
I: Determining Data.
Ashley K. can be described as 23-year aged white woman who was admitted to Warner Transitional Providers on 11/21/12. II: Main Complaint.
" I was a little troubled and upset right now. IDTC in Lafayette could not whatever it takes for meвЂќ. III: Informants.
Assessment information was given by patient. Interview was done in a exclusive room along with professional, and lead clinician. Other sources used for this kind of evaluation included documents by her prior two positionings.
IV: Basis for Consultation.
Customer was known Warner Transition Services simply by Indiana Developing Training Center of Lafayette. She started to be a candidate for Warner's system due to her progression through treatment, improved behaviors, and being able to function at penetration of00 than the majority of patients by her earlier placement. Individual was dismissed from express hospital and transferred to service. Patient probably will remain in Warner until she could be transitioned in a group house. The treatment team believes that Warner's program can improve her total functioning. The team also feels that the lady can benefit from a much more group orientated, and less limited environment. Versus: History of Present Illness.
The info obtained inside the assessment, and former records leads me to assume the patient has had a incredibly complex record. Documents received paint Ashley as being praised for manipulation, and making up stories. During the interview she was often vivid and visual when the lady began to explain details. Likewise, as the girl told her tale redirection was often necessary to stay focused around the question talked about. She will want to reply to questions with questions, and seemed to favor elaborating on certain issues, rather than improvement and complete the interview. Ashley was future with data stating " I usually damage by damaging myself while i talk, or hear from my personal familyвЂќ. She then folded up her shirt and showed me a bunch of superficial cuts onto her right equip. Patient appears to be a good tale teller, nevertheless a poor historian. During the assessment process treatments team was somewhat mixed up as to if some of the traditional details provided were based on Ashley himself, previous paperwork, or members of the family. VI: Psychiatric History.
Ashley provides historical diagnoses of PTSD and main depression, manufactured at the age of seven. St . Joseph County DCS became involved with her it happened in 1999 due to substantiated physical maltreatment by her father. The next year she was observed in the emergency room for a twenty-five pound weight-loss sustained in a single month. Currently Ashley reported sexual misuse by her father. The patient's dad previously had been investigated to get molesting a neighbor's kid. As a result, the sufferer and her siblings were removed from the home, and made wards of the point out. At some point they were returned to the home then simply Ashley's sisters made allegations that the girl had been " humpingвЂќ these people. In 2005 Ashley was at one time again reported a Child Looking for Services. Ever since then, patient patterns has been difficult to manage. She gets a documented history of defiance, property break down, aggression, and self-harm. Consequently, Ashley has had multiple psychiatric hospitalizations in various locations throughout the state of Indiana. VII: Medical History.
Patient has no known drug allergy symptoms, no surgical history, and achieved developing milestones promptly. Patient at present suffers from hypertension, GERD, and obesity. She is prescribed Toprol XL 25mg for HTN, and Zantac 150mg to get GERD supervision. Upon entry she was handed a TB skin check, ordered a CBC with diff, CMP, and TSH. All outcome was unremarkable. Sufferer is timetabled to have eyesight testing, and her perception teeth taken off bilaterally sometime in December 2012. VIII: Social History and Premorbid Personality.
As stated before the patient skilled...
References: Varcarolis, E. (2011 - 4th). Manual of Psychiatric Nursing jobs Care Strategies. New York: Elsevier/ 9781437717822
American Psychiatric Association DSM-TR (Text Revision) (2000). Diagnostic and Statistical Manual of Mental Disorders. Washington, D. C.: American Psychiatric Association