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Running Head: MENTAL HEALTH FINAL TREATMENT PLAN/ANALYSIS 1 Mental Health Final Treatment Plan/Analysis Emily McGonagle Chamberlain University
MENTAL HEALTH FINAL TREATMENT PLAN/ANALYSIS 2 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%
MENTAL HEALTH FINAL TREATMENT PLAN/ANALYSIS 3 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. Objective Physical Exam VS: Heart rate: 115 beats/minute and regular Respiratory rate: 29 breaths/minute Blood pressure: 152/84 mm Hg Oxygen Sat: 98% Room Air Weight: 110 pounds Height: 63 in Genera l: 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.

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