MSN 664 WEEK 4 ASSIGNMENT: PATIENT NARRATIVE NOTE

MSN 664 WEEK 4 ASSIGNMENT: PATIENT NARRATIVE NOTE

MSN 664 WEEK 4 ASSIGNMENT: PATIENT NARRATIVE NOTE

Weekly Patient Narrative Note

1. Date Patient Seen:
2. Chief Complaint: The patient states that he is very restless and talks a lot in school.
3. History of Present Illness: He has been diagnosed with PTSD, ADHD, insomnia and anxiety.
4. Mental Status Exam

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Appearance: He appears unkempt

General behavior: Fidgety and unable to sit still.

Speech and language: Patient talks a lot

Emotions: Difficulty in managing emotions

Thought and perception: Disruption in thoughts

Cognition: Difficulty in paying attention.

5. Diagnoses:9 – Unspecified Attention-Deficit/Hyperactivity Disorder
6. Signs & Symptoms: Include excessive talking, being unable to sit still and sleep problems.
7. Medication: The patient has in the past been on Buspirone (Rx) 15 mg daily (7.5 mg b.i.d), Seroquel 50 mg/day PO, Gabapentin 600 mg orally 2 times a day, Prozac 60 mg/day, Abilify 5 mg/day and wellbutrin 150 milligrams (mg) once a day in the morning.
8. Client progress to date: The patient has been treated for insomnia, ADHD, PTSD and anxiety. However symptoms of ADHD still persist.
9. Patient’s stated goals. The patient seeks to learn coping mechanisms for restlessness and insomnia (Caye, et al., 2019; Gunn, et al., 2019).
10. Teaching goals and self-help strategies along with the content of instruction: The patient will learn the importance of taking medications as instructions and never stopping taking them abruptly (Ströhle, et al., 2018).
11. Changes to the treatment plan: The patient is to start Wellbutrin XL 300mg daily, Buspirone 15mg daily and Seroquel 50mg po qhs for his anxiety, ADHD and PTSD and insomnia.

References

Caye, A., Swanson, J. M., Coghill, D., & Rohde, L. A. (2019). Treatment strategies for ADHD: an evidence-based guide to select optimal treatment. Molecular psychiatry, 24(3), 390-408.

Gunn, H. E., Tutek, J., & Buysse, D. J. (2019). Brief behavioral treatment of insomnia. Sleep Medicine Clinics, 14(2), 235-243.

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Ärzteblatt International, 115(37), 611.

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Weekly Patient Narrative Note: PLEASE MAKE SURE ALL OF THESE ARE COVERED IN THE NARRATIVE
1. Date Patient Seen
2. Chief Complaint
3. History of Present Illness
4. Mental Status Exam- Include all aspects of the MSE along with justification for findings. Do not use a template where you just check off the different components of MSE.
5. Diagnoses (established in this treatment course or new for today’s visit) with ICD-10 code for each
6. Signs & Symptoms that support the diagnoses (This is medical Decision-Making)
7. Medication with dose and frequency along with indication for treatment. The diagnoses and medication should be reflective.
8. Client progress to date if previously treated & on a current treatment plan (write n/a if this is first-ever treatment)
9. Patient’s stated goals.
10. Teaching goals and self-help strategies along with the content of instruction.
11. What changes to the treatment plan (if any) are needed at this time?
USE THIS PATIENT INFO TO MAKE YOUR NARRATIVE AND ADD REFERENCES PLEASE. THANKS. Any info I don’t have here, just make it up. Thanks
7/30/22
Info – Pt Reports he has always was had mental health issues as a child. States he would talk a lot and was very restless in school. State she was put on Concerta and Ritalin when he was a child. Reports he was dx’ed with anxiety and PTSD. Reports he’s been struggling . Reports being unorganized, Reports he just started college. Reports he has 2 children with a different woman and has a woman he’s with now who has 4 children. Reports his sleep at night is off as he struggles to stay asleep through the night. Reports he was prescribed Buspirone, Seroquel, gabapentin, prozac,. Abilify, and wellbutrin inn the past as well. Reports appetite is good. Denies any si, no injury to self, no psychosis.

Past Diagnosis
-ADHD
-Anxiety
-PTSD
-Insomnia

Age of Onset
– Symptoms started in childhood

Social Hx
-Works as a cleaner at a meat shop.
-Currently lives with his father
-Has 2 children and is dating a woman currently who has 4 children
-Was arrested twice in 2005 and 2012 for dealing drugs
Dx
F31.81 – Bipolar II Disorder
F41.1 – Generalized Anxiety Disorder
F90.9 – Unspecified Attention-Deficit/Hyperactivity Disorder
F43.10 – Posttraumatic Stress Disorder
F51.01 – Insomnia Disorder
Treatment Plan
Bipolar, Anxiety, ADHD, PTSD, Insomnia
-Start Wellbutrin XL 300mg daily
-Start Buspirone 15mg daily
-Start Seroquel 50mg po qhs
-Discussed s/e of meds, essence of taking meds as prescribed, not stopping meds abruptly. pt verbalizes understanding
f/u in 2 weeks