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Running Head: MENTAL HEALTH FINAL TREATMENT PLAN/ANALYSIS 1Mental Health Final Treatment Plan/AnalysisEmily McGonagleChamberlain University
MENTAL HEALTH FINAL TREATMENT PLAN/ANALYSIS 2After 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.oSex: femaleRace: African American Subject:CC:distressed, delusional, confused, extreme fear and anxietyHistory: 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, herhome was broken into, and she was raped and robbed. The housekeeper found her laying on the floor. Shewas 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 rhabdomyolysisSHx: Marital Status: widowedChildren: one daughterOccupation: retired school secretaryLiving Quarters: independent living facilityTobacco use: DeniesAlcohol use: DeniesIllicit drug use: DeniesPMHx:Chronic conditions are pernicious anemia, osteoarthritis, and urinary incontinencePSHx: hysterectomyAllergies: penicillinCurrent Medications:Multivitamin one-a-day for womenCyanocobalamin (vitamin B12) 1000mcgCapsaicin topical cream 0.075%
MENTAL HEALTH FINAL TREATMENT PLAN/ANALYSIS 3ROS:Systemic:Denies fever, chills, or recent weight gainHEENT: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 hematuriaMusculoskeletal: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.ObjectivePhysical ExamVS:Heart rate: 115 beats/minute and regularRespiratory rate: 29 breaths/minuteBlood pressure: 152/84 mm HgOxygen Sat: 98% Room AirWeight: 110 poundsHeight: 63 inGeneral: Shows signs of extreme fear and anxiety, is fidgeting on the exam table. She is unable to stop crying, is confused by what is happening, and has blood stains on her clothes near her groin.