It is anticipated that the initial discussion post should be in the range of 250-300 words. Response posts to peers have no minimum word requirement but must demonstrate topic knowledge and scholarly engagement with peers. Substantive content is imperative for all posts. All discussion prompt elements for the topic must be addressed. Please proofread your response carefully for grammar and spelling. Do not upload any attachments unless specified in the instructions. All posts should be supported by a minimum of one scholarly resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.
DISCUSSION POST:
Consider the following questions in your initial discussion post:
- Review the ‘S’ and ‘O’ data sets accessed through this link (attached file)
Construct a discussion that includes the following:
- An ‘Assessment’ (‘A’ of a SOAP note) section that is supported by the data sets reviewed.
- Assignment of an ICD-10 Code for each diagnosis you included in your ‘A’
- Identification of the subjective and objective data for each of the ‘Assessments’ (diagnoses) you included in the ‘A’.
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.
EXAMPLES:
#1
To complete a more appropriate diagnosis, I would need further information such as previous medical records and more detailed information. This would include more on her symptoms in the past and present, and I would need to gather information on how long the current symptoms have been going on with more information on other symptoms she may be having. I would need to conduct the following screenings: PHQ-9, PANSS, GAD-7, and the BSDS. The psychiatric assessment and interview need to be thorough to account for all possible concerns, current and past. This helps to select and understand the present disorder and diagnosis. It uncovers information needed to meet DSM-IV criteria., A diagnosis must have supporting information that meets the DSM-IV criteria to make the diagnosis for a specific disorder. Screening tools can easily be implemented during this process to help with the diagnosis process. Medical causes of her behavior would also need to be explored (Samartzis & Talias, 2020).
- The ICD-10 code I would assign this patient’s current diagnosis as F23 (DSM-IV – 298.8) – Brief Psychotic Disorder. This could change to other items with additional information such as F20.81 (DSM-IV – 295.40) Schizophreniform Disorder, F20.9 (DSM-IV – 295.90) Schizophrenia, F31.9 (DSM-IV) – Bipolar I – Unspecified or even F25.0 (DSM-IV – 295.70) – Schizoaffective Disorder – Bipolar type. The ICD-10 F23 code was chosen because of the following information from the about assessment (American Psychiatric Association, 2013):
- Speaking about alien doctors in the hospital wanting to take over
- Speaking of aliens invading earth when stealing food store for when this happens
- Talking about the city water being poisoned by aliens
- Reports of seeing aliens under the bridge that look like her
- Reports of her being raped by alien men
- Family hx of schizophrenia
- Reported headaches from alien surgery on her
- Reported sleep interrupted by aliens
- Interest/focus on alien invasion
- Being hyper because on the lookout for aliens
- Negative toxicology screen
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association Publishing.
- Samartzis, L., & Talias, M. (2020). Assessing and Improving the Quality in Mental Health Services. International Journal of Environmental Research and Public Health, 17(1), 249. doi:https://doi.org/10.3390/ijerph17010249.
#2
My initial assessment for this patient based on the subjective and objective data gathered would be F23- Brief Psychotic Disorder. Brief Psychotic disorder according to DSM-5 is the sudden onset of psychotic behavior that last less than a month followed by complete remission with possible future relapses. It is a transient disorder with the onset of one or more of the following psychotic symptoms: Delusions; Hallucinations; Disorganized speech; Gross disorganized or catatonic behavior. At least one symptom must be delusions, hallucinations or disorganized speech. (Stephen et al., 2021) This patient has one of more of the psychotic symptoms which are the following:
- Seeing alien doctors at the hospital and helping to take over
- Talking about the city water supply being poisoned by aliens
- Seeing aliens under the bridge that look just like her
- Reports that alien men have been raping her
- Reports sleep interrupted by aliens
The 3 essential elements of the History and physical in this patient with suspected brief psychotic disorder is present. She has shown at least one positive psychotic symptom such as delusion. The onset and duration of symptoms have yet to be establish, if it has not been present for less than one day or more than one month. Urine toxicology, Pregnancy test, TSH, electrolytes, LFT, UA are unremarkable. Further investigation is needed if the disturbance in behavior is otherwise explainable by another mood disorder, or medical conditions CT and MRI of the brain may be performed to evaluate for any underlying structural causes for the symptoms. If symptoms persist more than a month, Psychotic affective disorder, Schizophrenia-spectrum disorders, schizoaffective disorder needs to be ruled out (Stephen et., 2021).
Reference:
Stephen, A. (2021, July 6). Brief psychotic disorder. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK539912/.
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