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1 6 Assignment template Subjective Section Chief complainant The patient starts by saying, "I can't stop crying, all the time." The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her. History of present illness (HPI) L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently. Past psychiatric history The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure. Medication trials and current medication She has not tried any medications in the past, neither is she under any medication currently. Psychotherapy or previous psychiatric diagnosis The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder. Pertinent substance use, social, and medical history The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence. Allergies L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth. ROS General: No weight loss, fatigue or chills experienced by the patient. HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay. Skin: Her skin has not changed either is she having rashes. Cardiovascular: No chest discomfort or pains. Respiratory: She is not coughing or producing sputum, implying her respiratory is fine. Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain. Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains. Hematologic: No bleeding realized or enlarged nodes. Endocri ...
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1 6 Assignment template Subjective Section Chief complainant The patient starts by saying, "I can't stop crying, all the time." The patient complains that since she gave birth to her child two months ago, she has been experiencing mood disorders and difficulties falling asleep even after the baby is already asleep. She complains that especially when the baby cries, she loses her appetite and is not comfortable with her new body shape and size. She says nothing interests her, even writing, which was one of the things she loved before she gave birth. She does not want to contact her friends, and everything seems to be upsetting her. History of present illness (HPI) L.T is a 32-year-old black female who resents for psychiatric evaluation due to mood depression. The patient has not been prescribed any psychotropic drugs recently. Past psychiatric history The patient has never been examined or treated for any mental disorders in the past. Recently she was hospitalized for a standard childbirth procedure. Medication trials and current medication She has not tried any medications in the past, neither is she under any medication currently. Psychotherapy or previous psychiatric diagnosis The patient has no history of psychiatric illness and has not been diagnosed or treated with any mental health disorder. Pertinent substance use, social, and medical history The patient denies any use of alcohol or cases of drug abuse in the family. Although she says that her uncle was not an opioid abuser, he committed suicide using GSW. She is married and currently lives with her husband with their two kids. She has been working in the retail business for the past five years, but currently, she is a housewife. The patient grew up with her sister together with her both parents. She has been diagnosed with hypertension recently, and she is taking drugs labelled as labetalol 100mg for HTN, which she says that she sometimes forgets to take them. The patient has no legal history or any issues related to violence. Allergies L.T is allergic to codeine. She gave birth two months ago, which automatically means that she is lactating. Currently, she is not using any form of contraceptive, and she has had no desire for sex since she gave birth. ROS General: No weight loss, fatigue or chills experienced by the patient. HEET: Her vision is the same no issues of double vision or jaundice. Her ears, nose and throat are okay. Skin: Her skin has not changed either is she having rashes. Cardiovascular: No chest discomfort or pains. Respiratory: She is not coughing or producing sputum, implying her respiratory is fine. Gastrointestinal: She has eventually lost her appetite and wants to lose weight, although she is not vomiting or feeling abdominal pain. Genitourinary: The urine colour or odour has not changed, and she is not experiencing any burns during urination. No headaches, no back or joint pains. Hematologic: No bleeding realized or enlarged nodes. Endocri ...
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16Assignment templateSubjectiv
KiyokoSlagleis
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As our knowledge about addiction is increasing the association between mental illness and addiction is better understood. The controversy about the appropriateness of the term Dual Diagnosis to describe such a heterogeneous group of patients has sparked a debate on treatment and assessment models. It highlighted the fact that as far as treatment modalities are concerned, one size might just not fit all. Dr Mouton reviews current knowledge on comorbidity in the addiction field. Focusing on more than psychiatric comorbidity, he also looks at physical, social, psychological, spiritual and cultural components affected by addiction. Describing the role of the psychiatrist in addiction care he poses the questions: What if dual diagnosis is actually the key to better understanding of our patients? What if this knowledge leads to more individualised treatments? And are we ready for personalised treatment in the addiction field?
DR CONSTANT MOUTON - COULD DUAL DIAGNOSIS BE THE KEY TO PERSONALISED TREATMEN...
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The lecture has been given on Dec. 14th & 21st, 2010 by Dr. Saman Anwar.
Psychiatry 5th year, 3rd & 4th lectures (Dr. Saman Anwar)
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Initial Psychiatric Interview/SOAP Note Template Criteria Clinical Notes Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) Subjective Verify Patient Name: Susan DOB: not provided Minor: NA Accompanied by: self Demographic: NA Gender Identifier Note: Female CC: “I have been feeling anxious, depresssed, high blood pressure, irregular heartbeat, elevated body temperature, crying spells for the last 2 days” . HPI: Susan is a midde aged woman who reports to the healthcare clinic reporting several symptoms that she has observed over the period of the last two days. She reports having high blood pressure, an irregular heartbeat, depression, anxiety, and an increase in body temperature. Susan doesn't realize that she shows signs of alcohol dependence and physiological dependence, which downplays the seriousness of her alcohol usage. This diagnosis is supported by the withdrawal symptoms that appear to be becoming more tolerable as well as by the sustained and increased alcohol consumption despite the harm it does to social interactions and job performance. She has also increased her alcohol consumption to ease withdrawal symptoms. s He has a history of drinking, which has caused him to skip work and even get arrested. She downplays her alcohol consumption and justifies how often and how much she drinks. Pertinent history in record and from patient: Alcohol withdrawal During assessment: Patient is cam and corparative Patient seemed to be suffering from serious cases of both anxiety and despair judging from her crying spells. Patient denies hallucinating. The patient has nomal thought process. . SI/ HI/ AV: patient denies signs of suicidal ideation and violent behavior. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported Past Psychiatric Hx: Previous psychiatric diagnoses: NKDA Describes stable course of illness. Previous medication trials: not reported Safety concerns: History of Violence to Self:none reported History of Violence t o Others: none reported Auditory Hallucinations: not reported Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Priorsubstance abuse treatment: not reported Trauma history: Client reveals no history of traumatic experiences (such as abuse, domestic violence, or exposure .
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School Mental Health Teacher Training
TeenMentalHealth.org
Initial Psychiatric Interview/SOAP Note Template There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting. Criteria Clinical Notes Informed Consent Informed consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability/capacity to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion) Subjective Verify Patient Name: DOB: Minor: Accompanied by: Demographic: Gender Identifier Note: CC: HPI: Pertinent history in record and from patient: X During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME. Patient self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy, no reported changes in concentration or memory. Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. Patient does not report hallucinations, delusions, obsessions or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature. SI/ HI/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA. (medication & food) Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C. Surgical history no surgical history reported Past Psychiatric Hx: Previous psychiatric diagnoses: none reported. Describes stable course of illness. Previous medication trials: none reported. Safety concerns: History of Violence to Self: none reported History of Violence t o Others: none reported Auditory Hallucinations: Visual Hallucinations: Mental health treatment history discussed: History of outpatient treatment: not reported Previous psychiatric hospitalizations: not reported Prior substance abuse treatment: not reported Trauma history: Client does not report history of trauma including abuse, domestic violence, witnessing disturbing.
Initial Psychiatric InterviewSOAP Note Template There are diff.docx
Initial Psychiatric InterviewSOAP Note Template There are diff.docx
LaticiaGrissomzz
Discussion 1 Marcia The relationship between mental illness and religion continues to be an ongoing debate. An individual’s values and belief systems tend to directly influence the perception of mental illness and the course of progression or suppression (Amedome & Bedi, 2018). The creator of the psychoanalytic model, Sigmund Freud, was said to be skeptical and antagonistic toward religion’s direct correlation to mental illness; Freud believed that less religious people were mentally healthy (Amedome & Bedi, 2018). Many cultures believe that the cause of mental illness is the “Mark of the beast” or a spiritual curse requiring the elders, parishioners, and priests to rid the body of demons/spirits for healing. The utilization of religious practices as a coping mechanism is superior in various cultures. Religious practices of faith, prayer, fasting, and communion tend to provide a sense of hope and positive outcomes (Amedome & Bedi, 2018). As a practicing clinician in the primary care setting, many patients with mental illness become hyper-spiritual during therapy, often resulting in abrupt discontinuation of medical care. Many patients would present to the clinic with bibles, layers of crosses around their neck, or continuously reciting scripture passages. Religion varies among cultures and ethnicities and is thought to directly correlate to mental illness, suffering, and God’s will (Amedome & Bedi, 2018). In the referenced case, the patient was not initially religious, which is very interesting, but after believed possession, he immediately sought to eradicate the spirit at a local church. Although not religious, he believed that multiple religious exorcisms were superior to western medicine. (psychotherapy). Durand et al. (2020) define psychopathology as the study of psychological disorders. Psychological disorders are challenging abnormal behavior associated with distress, impairment in functioning, and a response that is not normal or culturally accepted (Durand et al.,2020). The referenced patient’s behavior has demonstrated abnormal and mild functional impairment, warranting psychiatric evaluation. The scenario meets the criteria for psychotic disorder: non-bizarre delusions of control, one’s body or actions are being acted on or manipulated by some outside force (American Psychiatric Association [APA], 2017). Supporting data for diagnosis is the patient’s belief that a spirit entered his body through his rectum, controlling movement and speech after using a Ouija board for two months. Although the patient believes this scenario to be actual, the reality proves his beliefs to be impossible and pathologically false. Mental health clinician frequently uses the DSM-5 to diagnose mental health disorders in the clinical setting. The focus of the DSM-5 is on identifying symptom clusters that differentiate between normal and psychopathology, mainly focusing on the duration and severity of symptoms (Amedome & Bedi, 2018). The most challengin ...
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