Chronic Pain or Mental Illnesses - Case Study Example

Download file to see previous pages Health assessment on the other hand refers to the plan of care that seeks to identify the needs of an individual and how they will be addressed. This essay thus discusses two health assessment histories that can be performed on a person suffering from mental illness; a summary of the findings and a concise note using the subjective, objective, assessment, and plan (SOAP) format with each patient's encountered findings. The essay also provides some examples to support the findings.
The following are two health assessment histories that I would perform for patients with mental illness:

First, Psychiatric history: this refers to the mental profile of the patient. It involves critical information about the patient’s chief complaint, their present illness, and any psychological ailments they have made before or in the onset as well as after the mental illness (Hughes, & Kleespies, 2002). In this stage, more specific and closed-ended questions could be asked during the assessment process so that the details of the patient’s illness or rather their profiles can be obtained. For instance, a patient responds that “I am just depressed.” Can be engaged further in questing through asking leading questions like, how long has the depression been? How often has the situation been? Or how long has this taken? Questions such as such enable an in-depth understanding of the patient thus enabling a good history assessment of the mentally ill patient
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Secondly: the medical history of the patient. This is medically understood as the patient’s past and even the present and future that may communicate information relevant to their future, present, and past health (Hughes, & Kleespies, 2002). It is an account of all the medical problems and events that an individual has experienced. It also includes other medical facts and treatments or injuries that an individual has been through. As much as possible, they are taken in the patient’s own words. The drugs taken, past and present hobbies used by alcoholics as well as an exhaustive survey of any symptoms that may not have been covered by the patient. This medical history is an important part of the health assessment of a patient with mental illness.
A concise note using the subjective, objective, assessment and plan (SOAP) format with each patient's encountered findings is as follows

Components of the SOAP Note
Patient’s Psychiatric History
The patient is a 41-year-old black woman complaining of restlessness, little need for sleep, racing thoughts, inability to concentrate, alcohol abuse, and high sex drive.
Patient Medical History
• Serious illness in the past two years
• Taken mood stabilizer (lithium carbonate) every day for 2 weeks in the past month
• Was on valproate last year.
• Sometimes experiences episodes of mania.
Family History
• Patient’s father suffered from bipolar
• Patient was raised by an abusive single parent

Patient Physical Examination
• Patient looks thin
• Patient claims excessive loss of weight
• Talks very little.
• Patient smells alcohol

Summary of the findings
The 41-year-old woman complaining of restlessness, little need for sleep, racing thoughts, inability to concentrate, alcohol abuse, and high sex drive has shown symptoms and behaviors that relate to certain disorders or conditions. Following the physical observation and the interview conducted, the following findings have been made:
The first symptoms of decreased desire for sleep, flight of ideas or racing thoughts and inability to concentrate, and abuse of alcohol suggest the existence of mental illness. However, which mental illness is this?

Following the interview, the findings reveal a person finding refuge in alcohol and having had a history of serious illness and hospitalization. Additionally, the use of stabilizers justifies a depressive moment in the life of this patient. Therefore, it is justifiable to diagnose these symptoms as Bipolar disorder. This is a mental illness with a chronic episode that is associated with behavioral disturbances.

Conclusion
Mental illness relates to mental conditions and affects one's moods, behavior, and thinking such as major depression which may cause psychomotor retardation as well as agitation among others. ...Download file to see next pages Read More