Premium Essay

Altered Mental Health Case Study

Submitted By
Words 781
Pages 4
Case Summary

The patient, a 23-year-old male (date of birth September 30, 1994), presented to the facility’s Emergency Department on February 27, 2018, with a history of schizophrenia, seizure disorder, polysubstance abuse (ETOH, marijuana, heroin and BZDs), opiate intoxication, depression and suicidality. The patient was admitted to the Medical Center on February 27, 2018.

The following diagnoses were submitted: Admitting Diagnosis of altered mental status;
Principal Diagnosis of seizure disorder; Secondary Diagnoses: enterocolitis due to Clostridium difficile; suicidal ideation; sedative hypnotic or anxiolytic dependence with withdrawal; opioid dependence with withdrawal; other psychoactive substance use unspecified with mood disorder; …show more content…
Upon detailed review of the medical record, inclusive of the Itemized Bill (listed in chronological order, each specific service and supply/drug billed are supported by the entries and reports as medically necessary and identified as provided in the most appropriate setting: The Room and Board -Isolation and Medical-Surgical Bed Services for 20 days, based on the patient’s diagnoses and treatment requirements. The services are supported as being actually furnished as ordered by the physician(s). There is no evidence of services being duplicately billed.

The medical record evidences no period, during the admission at issue, when the patient was in an alternative level of care. There are no undocumented charges.

Review of the medical documentation confirms that the charges are substantiated by the medical record and adhere to the ICD 10 CM Official Guidelines for Coding and Reporting, Section II. I Admission from Observation Unit and Section III. Reporting Additional Diagnosis; and are medical necessary and appropriate, delivered in the most appropriate setting, ordered and actually

Similar Documents

Premium Essay

Untreated Mental Illness

...Criminal activity due to mental instability has been a very hot topic recently and researchers are turning towards mental health facilities and budgets allocated for mental health as an answer to reduce the amount of these incidents. Though researchers have consistently found that traditional attacks are not largely motivated by and underlying mental disorder or condition, the same cannot be said of lone-wolf attacks. The presence of untreated mental illnesses and/or undiagnosed mental disorders allows for the progression of violence in these individuals and could lead to a potential catastrophe. An example of a mental illness causing a catastrophe would be the shooting in Newtown, Connecticut. Medical experts at Yale University had called for measures to help Adam Lanza, the offender, in the years prior to his attack at Sandy Hook Elementary School but nothing was ever accomplished. “Allowing ailments that are responsive to medication to go untreated and resisting other kinds of emotional support were missed chances for the parents to help their son.” Said by Dr. Julian Ford, an author of the report of the University of Connecticut’s Center for Trauma Recovery and Juvenile Justice. This incident, in which 20 students and 7 adults were shot...

Words: 1181 - Pages: 5

Premium Essay

Dissociative Identity Disorder Analysis

...position in psychopathology; in previous eras and still, in modern-day society, the idea and validity of the occurrence of dissociative identities, inside a single person, has caused much debate and conflict between mental health care specialists (Traub, 2009). It produces an extraordinary combination of both approval and refutation in the scientific world. Starting with approval, DID is a formally documented diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM; APA, 2013) in addition to the International Classification of Diseases. Furthermore, the study of DID yields a mild but stable output of publications supporting cases of the disorder in nations all...

Words: 1222 - Pages: 5

Premium Essay

Psychoanalytic Models

...of a handful of individuals pivotal in the history of civilization who altered the way humans think about themselves,” (Schultz, 2011, p. 287). These words reveal much about the father of psychoanalysis, and about those who built upon his original findings. The “official” introduction of psychoanalysis happened in 1895, when Freud had his first book published. Freud’s psychoanalysis was introduced while several other schools were in full swing, and before behaviorism or Gestalt psychology were even a twinkle in Watson or Wertheimer’s eyes. Because psychoanalysis was the first “school” of its kind – that which was neither purely scholarly nor purely scientific – it is still to this day not quite comparable to the other mainstream schools of thought. Because psychoanalysis deals with abnormal behavior and the unconscious, the other schools of thought simply brushed it aside. It is often wondered what influences helped to create the idea of psychoanalysis. There are three main components to the answer to this question: 1. Philosophical speculations about unconscious psychological phenomena 2. Early ideas about psychopathology 3. Evolutionary theory (Schultz, 2011, p.288) These three ideas sparked many questions and led Freud and others on their journey to understanding the unconscious mind of the human being. Beginning with Leibnitz’s idea of monadology - Leibnitz’s belief that “mental events (which are composed of the activity of monads) had different degrees...

Words: 1301 - Pages: 6

Premium Essay

S. A Case Study Nursing

...This is a case study of S.A. who is 35 years old female who is brought to the ED at NY Medical Center (NYMC) by EMT via ambulance in the reason of altered mental status. S.A. was pacing in circles outside her apartment building in the middle of the night and she was speaking incoherent sentences to “imaginary people”. S.A. has past medical history of tonsillectomy, adenoidectomy secondary to frequent Strep. throat, and diagnosed with asthma, scoliosis, and depression. She had back surgery for herniated disk and stenosis in May 2015. She also has past history of alcohol poisoning and drug overdose. Since then, she began Alcoholic Anonymous and she was “clean” for six months when she admitted beginning drinking alcohol occasionally. After she returned to work in September 2015, she was found that she lost focus on three different occasions when she was working in the surgery room. She admitted that she had addiction problem since...

Words: 337 - Pages: 2

Premium Essay

The Legalization of Marijuana

...emptied cigars known as Blunts. People also bake Marijuana in sweets such as cookies candies and cakes. When an individual smokes marijuana short term the toxic chemicals immediately rushes from the lungs and into the blood stream. The blood steam immediately distributes the chemical to the brain and the rest of the organs in the body. The parts of the brain containing the highest amount of receptors are affected by THC that involves altered senses, sense of time, mood change, impaired body movement, memory, difficulty thinking, and solving problems. Long term use also affects brain development. For example if a teenager use the drug it can negatively affect the building of the brains connections between spaces needed for thinking memory, and learning. These affects could last a long time or perhaps may become permanent depending on the body. For example, a study showed that people who started smoking marijuana heavily in their teens and had an ongoing cannabis use disorder lost an average of eight IQ points between ages 13 and 38. The lost mental abilities did not fully return in those who quit marijuana as adults. Those who started smoking marijuana as adults did not show notable IQ declines (Meier, 2012). Smoking marijuana also affects the body physically as well as mentally. It causes lung irritation,...

Words: 640 - Pages: 3

Premium Essay

Psy 210 Case Study

...Case study By Kevin Whelan Axia College of University of Phoenix PSY 210 Dean Marzofka January 11, 2011 Final Project: Case Study What are the causes of stress in Michael’s or Jennifer’s life? How is stress affecting Michael’s or Jennifer’s health? I chose to analyze the second case study, Michael the airline pilot, as I am in the same line of work, (aviation), I hope to be able to relate to the subjects symptoms, behaviors and anxieties and be able to relate positive and practical analysis and possible recommendations for coping with the anxieties of life in the profession of aviation. The primary stressors in Michael’s life are most likely a combination of the following: Chest pain, divorce and all the legal technicalities like paper work and the emotional implications, the end of a long marriage and loss of a close friend due to the commitment termination, (his wife), the difficult custody battle for his two children, ages 10 and 12, a heavy work schedule that keeps him away from his family two weeks a month, work concerns of possible lay offs in the future, the burden of a new town house in uncertain financial times, and finally, (if that all isn’t enough for one to deal with), unknown physical medical condition as a result of the increasing regularity of the chest pains. How are these stressors affecting Michael’s or Jennifer’s self-concept and self-esteem? In Michael’s case, self esteem has not been directly reflected in the case study, for instance...

Words: 1690 - Pages: 7

Premium Essay

Analyzing Psychological Disoreders

...Analyzing Psychological Disorders 3/8/2013 Psy/240 Dr. Elizabeth Kindell Biopsychology is the study of the central nervous system and how it affects mental health or illness. In this paper I will discuss the psychological disorder known as Schizophrenia. I will evaluate the brain areas that are affected by this disorder, some of the possible casual factors, the characteristics symptoms, the neural basis and the drug treatment that works. The case studies I have chosen to review are Generalized Anxiety Disorder and Anorexia Nervosa, the eating disorder. I will use the nature vs. nurture theories to analyze these two disorders. I will also discuss the accepted drug therapies and alternative treatment for these two disorders. Part A: Schizophrenia Schizophrenia is known as a “splitting of psychic functions” (Pinel 2001, pg. 467). It is a chronic brain disorder that affects close to 2.5 million Americans and more than 24 million people worldwide. Schizophrenia is a mental disorder that makes it hard for the person suffering to tell the difference between what is real and not real. They have a difficult time having normal emotional responses and acting normally in social situations. A person that has Schizophrenia has a significant loss of brain gray matter. Neuroscientist have detected up to 25% loss of brain...

Words: 1907 - Pages: 8

Premium Essay

Psych Nursing Safe Staffing

...Staffing on the Inpatient Psychiatric Unit at the University of Virginia Hospital University of Virginia School of Nursing Margaret Halladay, Lillian McDonough, Chelsea Bateman, Olivia Robison, Elizabeth Whitsett, Hannah Knabe, Janie Rhodes, and Fangzhong Luo On our honor, as UVA students, we have neither given nor received aid on this assignment. Margaret Halladay, Lillian McDonough, Chelsea Bateman, Olivia Robison, Elizabeth Whitsett, Hannah Knabe, Janie Rhodes, and Fangzhong Luo Introduction The nursing students working on 5E, the psychiatric unit at the University of Virginia, identified patient safety as a clinical problem related to inadequate staffing.  Previous research revealed that 63% of the staff on this unit identified that inadequate staffing greatly affected patient safety.  In order to research this issue further, the nursing students developed a follow-up survey that would help to identify the aspects of patient safety that are most affected.  By understanding which aspects of patient safety create an issue on this unit, the group will develop an intervention with increasing safety as the expected outcome.   Safety on this unit is difficult to measure because the unit does not face the same problems that staff encounter on Medical Surgical Units.  One way to measure safety on 5E is to review the number of patient falls.  Data was obtained that revealed in November of 2012, 5E reported the most falls of any unit in the hospital.  Other safety markers...

Words: 4654 - Pages: 19

Premium Essay

Sexual Harassment In The Workplace

...taught to deal with it from an age as early as grade school. All of these examples constitute as sexual harassment against women, but many people seem to overlook that in some cases, the roles are reversed and men can also be victims of sexual harassment. According to a study founded by the Equal Employment Opportunity Commission, “the percentage of complaints by men went from 11.6% in 1997 to 17.6% in 2013” (p. 16). Though the amount of reported sexual complaints and the amount of sexual harassment that actually happens are not proportional, ideally, society will eventually allow both men and women to speak up about their experiences, equal punishment will be applied to all...

Words: 799 - Pages: 4

Premium Essay

Geri Case Study

...Case study #1 1. The priority teaching would be to never abruptly stop taking the medication especially without consulting your physician, but try to take it in the morning so she would not have to get up a lot during the night to empty her bladder. 2. Decreased cardiac output r/t increased vasoconstriction aeb variations in blood pressure readings a. Monitor and measure blood pressure in both arms, using a manual technique for an accurate reading b. Monitor response to medication to control blood pressure. Give fluid and sodium restriction as indicated Disturbed Sleep Pattern r/t use of prescription diuretic aeb awaking various times in the middle of the night * instruct patient to take hctz in the morning to avoid waking up at night * assist the patient to identify envoiormental factors that make sleep difficult. Knowledge deficit related to lack of information about the disease process and self-care as evidence by patient lack of complaiance with medications. * Describe the nature of the disease and the purpose of the procedure and the treatment of hypertension * Explain the importance of a peaceful environment and theraupetic, and management of stressors. 3. Two non pharmacologic ways of managing hypertension include limiting your alcohol intake and the DASH diet which includes a diet that encourages you to reduce sodium intake and eat foods rich in nutrients such as potassium, calcium and magnesium. ...

Words: 1595 - Pages: 7

Free Essay

Application of Clinical Psyhchology: Betty Ford

...PSY/480 March 30, 2015 Tara Thompson Application of Clinical Psychology: Betty Ford Substance abuse can stem from a variety of biological, psychological, and social factors. These factors may vary from addict to addict, and it is the role of clinical psychology to examine the roots of addiction, and what type of treatment, such as interventions, would apply to and possibly work best for each individual. Interventions have to be rational as they apply to a patient, and the clinical psychology professional would have to have a plan as to who is involved, where will it be, what should happen, and what specific areas the intervention will focus on. We will examine the case study of Betty Ford, and uncover the possible reason for addiction as well as what type of interventions may work best and why. The Case of Betty Ford Many have heard of the Betty Ford Clinic, but most think Betty Ford, former first lady opened the clinic up because she wanted to help substance abuse addicts. In fact, that is precisely what she wished to accomplish, but for reasons other than just helping. Betty Ford was an addict herself. In 1978, Ford admitted that she was an addict, and a week later went into a treatment program. Inspired by the ability to overcome drugs and alcohol through treatment, in 1982, the Betty Ford Clinic was opened. Substance abuse doesn't lend itself to a particular economic, religious, academic, or cultural status. There are, however, clues to what may aid substance...

Words: 1473 - Pages: 6

Free Essay

The Many Faces of Dissociative Identity Disorder

...The Many Faces of Dissociative Identity Disorder Abstract This research paper aims to explore the mental disease known as Dissociative Identity Disorder (DID), previously known as multiple personality disorder. I explore the meaning, symptoms, and effects of DID. My research describes those diagnosed with DID and the probable reasons of why they have the disorder. This study also explains the many different treatments and the effects those treatments might have on a person that has the disorder. I include a research study done on someone diagnosed with DID, the method used to help treat her, and the results of her treatment. Lastly, I state my opinion on DID and the methods I believe with help people prevent, treat, and cope with Dissociative Identity Disorder. The Many Faces of Dissociative Identity Disorder Dissociative Identity Disorder (DID), previously known as Multiple Personality Disorder, is a mental condition where a person possesses two or more different personalities which may alternate within the individual’s conscious awareness. A person living with DID many have as little as two personalities, referred to as alters, or as many as 100, though the average is about ten. Alters may exhibit differences in speech, behaviors, attitudes, thoughts, and gender orientation. They may even have physical differences, such as allergies, right-or-left handedness, or the need for eyeglass prescriptions. At least two of these personalities assert themselves repeatedly to...

Words: 1849 - Pages: 8

Premium Essay

Are People with Mental Issues at Increased Risk of Committing Violence

...Are people with mental health problems at increased risk of committing violence? | Holly ButlerCCJ10January 27, 2015 | Abstract There has been significant interest in Australia and indeed the world as to whether people with a mental illness are at increased risk of violence. In particular, the diagnosing of current or even future offenders has offered a wide insight not only into mental illness as a stand-alone but to whether it is a major trigger in acts of violence. Offenders with mental illness have attracted substantial attention over the recent years, given their prevalence and poor outcomes. A number of interventions have been developed for this population (e.g., mental health courts) and they share an emphasis on one component as the foundation of the problem: mental illness. Focusing soley on psychiatric services inadequately tie in with the policy goal of reducing recidivism. The validity of mental illness being linked t criminal behavior points towards moderated arbitration techniques and the effect of mental illness on other “recidivism” is to some extent interceded by system impartiality and shame. The recognition of mental illness being tied to offenders been identified as a feasible tool to decrease the escalating level of offending amongst juveniles, and indeed has been implemented in varying forms as a diversion away from the criminal justice system. In this essay, the notion of people with mental health problems are not at increased risk of committing...

Words: 2058 - Pages: 9

Free Essay

Marijuana in California

...for the November 4, 2014 ballot as an initiated state statute. The measure would have: * Decriminalized marijuana and hemp use, possession, cultivation, transportation, or distribution. * Required case-by-case review for persons currently charged with or convicted of nonviolent marijuana offenses, for possible sentence modification, amnesty, or immediate release from prison, jail, parole, or probation. * Required case-by-case review of applications to have records of these charges and convictions erased. * Required the California State Legislature to adopt laws to license and tax commercial marijuana sales. * Allowed doctors to approve or recommend marijuana for patients, regardless of age. * Limited testing for marijuana for employment or insurance purposes. Bared state or local aid to enforcement of federal marijuana laws. Proposition 215: Text of Proposed Law This initiative measure is submitted to the people in accordance with the provisions of Article II, Section 8 of the Constitution. This initiative measure adds a section to the Health and Safety Code; therefore, new provisions proposed to be added are printed in italic type to indicate that they are new. PROPOSED LAW SECTION 1. Section 11362.5 is added to the Health and Safety Code, to read: 
    11362.5. (a) This section shall be known and may be cited as the Compassionate Use Act of 1996. 
   (b)(1) The people of the State of California hereby find and...

Words: 2247 - Pages: 9

Premium Essay

Gage

...of the brain through research, inference, experiments and actual real life occurrences. Such was the case of Phineas Gage (1823 – 1860), a young foreman on the railroad in the mid 1800’s who survived a blasting accident which destroyed a part of his brain. Documentation on Mr. Gage’s health and personality before and after the accident opened the door to the role of the brain in cognitive functions. Phineas Gage’s accident and apparent recovery precipitated the idea that there was a connection between the human brain and the personality. First, prior to Mr. Gage’s phenomenal recovery from the loss of a substantial part of his brain, scientists believed that the brain was an entire “organ”, and that all of it was needed to function at all. The incidence with Phineas’ recovery and his continual capability to function altered scientific thinking substantially. Secondly, the adaptation that he made in his personality opened further doors for studying the cognitive adaptability of the brain. According to friends and collegues, Gage was no longer Gage. Once a friendly and affable, easy to get along with individual, he became stubborn, argumentative and forgetful, unable to organize his life in a reasonable manner. He could no longer hold down a job. Phineas Gage died 12 years after a rod pierced his skull and permanently damaged his frontal cortex. The scientific studies that followed the reports of Phineas Gage’s accident and recovery led scientists to determine that the...

Words: 619 - Pages: 3