Boeing is labor intensive, capital intensive, or both. has boeing
Uncategorized
After reading the article “Boeing’s Secret” and watching the video “How a Boeing 787 Dreamliner is Built,” discuss in 400 Words if you believe Boeing is labor intensive, capital intensive, or both. Has Boeing established the “network effect” for their product?
Video:
Article:
On Dec. 11, 1996, Boeing Chairman Philip M. Condit closed the deal of his career. After a relentless three-year courtship, he persuaded the initially reluctant directors of defense giant McDonnell Douglas Corp. to agree to a merger. The combination would create the world’s largest aerospace company — the first manufacturer ever with the ability to build everything that flies, from helicopters and fighter jets to space stations. “This is, I believe, a historic moment in aviation,” Condit proclaimed at a Dec. 15 press conference.
But far from the glare of TV cameras, a disaster was quietly unfolding inside Boeing Co.’s sprawling factories — one that would ultimately wind up costing billions of dollars, cause several executives to lose their jobs, and lead to claims of accounting fraud. Facing an unprecedented surge in orders because of a booming economy, workers were toiling around the clock, pushing the assembly line to the breaking point. At the same time, the company was struggling to overhaul outdated production methods.
These pressures were building up to what was, in essence, a manufacturing nervous breakdown. In the weeks after the merger announcement, parts shortages and overtime approached all-time highs — triggering red warning signals in Boeing’s colorcoded system for monitoring factory health. As costs went through the roof, the profitability of airliners such as the 777 swooned. A special team formed to study the crisis in May, 1997, issued a report with a blunt conclusion: “Our production system is broken.”
If investors had understood the scope of the problems, the stock would probably have tumbled and the McDonnell deal — a stock swap that hinged on Boeing’s ability to maintain a lofty share price — would have been jeopardized. But shareholders never got the full picture until well after the merger was completed on Aug. 1, 1997. Top executives “were hoping against hope that none of the problems would bubble up before they got the deal done,” says a Boeing ex-official.
Their wish came true, and the deal sailed through. Recognizing that the bad news would have to come out eventually, company leaders started debating how it should be released. One public-relations manager lobbied for disclosure on Sept. 6 or Sept. 13 — the dates of the funerals for Princess Diana and Mother Teresa — when a grieving public would presumably overlook the story. Those proposals were nixed. On Oct. 8, former McDonnell CEO Harry C. Stonecipher, by then Boeing’s president and chief operating officer, shot an e-mail to Condit. “We do know for certain that there is a big surprise coming, and I think we owe the Street a heads-up. We have an unmitigated disaster on our hands and need some very candid damage control,” he wrote in an e-mail that was disclosed in a securities-fraud suit filed against Boeing in Seattle.
Condit, who in his 32 years at Boeing had yet to experience a failure, responded that the disclosure should be delayed. “My bias is to soften the third-quarter hit with some warning,” he wrote. “Assuming the scale of the problem remains, use the fourth quarter to prepare the Street to take the real hit then.”
On Oct. 22, Condit made the bombshell announcement: The company’s massive production problems would force it to write off $2.6 billion — by far the biggest charge in Boeing’s history. Overnight, shares fell 8%, to $49.88, wiping out about $4.3 billion in value. As investors digested the scope of the mess, the company lost years of hard-earned credibility and the stock fell a further 12%, to 43, by Oct. 27. The stock stayed in a trough throughout 1998 and won the dubious distinction of being dog of the Dow that year.
The story of how Boeing kept its 1997 production disaster secret has never been made public. Although the company subsequently fixed the assembly-line problems — and it has recently received praise for its diversification efforts — the tale provides a sobering view of how easily management can keep investors in the dark. It also sheds light on the little-known “program-accounting” method used in aerospace to this day. A controversial system that many analysts criticize for its lack of transparency, it continues to give Boeing broad leeway to goose earnings — and to make it one of the toughest companies in America to evaluate. In a deal approved by U.S. District Judge Thomas S. Zilly on Feb. 20, 2002, Boeing settled a private securities-fraud suit over the 1997 episode for $92.5 million. The company did not admit guilt. Although some of the evidence uncovered by the plaintiffs’ lawyers was revealed in court documents, the vast majority was locked under seal at Boeing’s request.
In a three-month investigation, BusinessWeek has reconstructed this hidden chapter in the company’s history — and analyzed its current implications. New details supplied by several inside witnesses indicate that Boeing did more than simply fail to tell investors about its production disaster. It also engaged in a wide variety of aggressive accounting techniques that papered over the mess. Critics say the company should have taken charges for the assembly-line disaster in the first half of 1997, even if it meant jeopardizing the McDonnell merger. They also claim that Boeing took advantage of the unusual flexibility provided by program accounting-a system that allows the huge upfront expense of building a plane to be spread out over several years — to cover up cost overruns and to book savings from efficiency initiatives that never panned out. “Boeing managed its earnings to the point where it got caught,” says Debra A. Smith, a partner at Constraints Management, a Seattle-area manufacturing consultancy, and a former senior auditor at Deloitte & Touche who worked on the company’s account during the early 1980s. “Boeing basically decided in the short run that [managing earnings] was a lesser evil than losing the merger,” adds Smith, a onetime accounting professor at the University of Puget Sound in Tacoma, Wash.
At a time when investors are asking themselves how far Corporate America can be trusted, the Boeing saga provides rich new evidence that companies have much greater leeway to manipulate their numbers than most people suspect. The aerospace giant was a widely held blue chip that had a huge short-term incentive to prop up its stock price. Taking advantage of an investment community willing to tolerate the company’s opaque reporting system, executives managed to conceal fundamental operational problems for nearly a year. Some of these officials, including Condit, are still at Boeing. To this day, they insist that they had no obligation to disclose cost overruns when they occurred in the first half of 1997 — which raises the question of how swiftly they would let investors know if a similar problem arose today.
As is often the case, none of the outside watchdogs ever barked. The board never forced Condit to come clean about the company’s production problems. Stock analysts and business journalists underestimated them. And although the company’s auditor, Deloitte & Touche, raised red flags about Boeing’s troubles, it doesn’t seem to have put much pressure on its big client to share this information with investors (page 120). As a result, Boeing’s financial reporting in early 1997 bore little relationship to its business reality. When the company finally disclosed its problems, “I was stunned,” recalls Richard J. Glasebrook II, managing director of Oppenheimer Capital, owner of 5% of McDonnell at the time. “I thought that Boeing had the building of commercial aircraft down cold.”
For its part, Boeing insists it never misled shareholders at all — and that critics and plaintiffs’ lawyers are holding the company up to unreasonable standards. Noting that the construction of planes is an incredibly complex and expensive endeavor, it says that managers told the public about the 1997 production problems as soon as they were legally required to do so. It also points out that the Securities & Exchange Commission never filed charges. Boeing defends program accounting as a legitimate way to report performance and notes that its accounting decisions were approved by Deloitte-which was not named in the fraud suit. All of the key players in the drama, including Condit, Stonecipher, and former Chief Financial Officer Boyd E. Givan, declined to comment. “Boeing and its senior management always tried to do the right thing,” the company wrote in a letter to BusinessWeek. “Boeing and its executives frequently disclosed Boeing’s production difficulties.” Deloitte also insists it acted properly.
So why did Boeing spend $92 million to settle fraud claims? General Counsel Douglas Bain says the company did not want to risk litigating complex accounting issues in front of a lay audience. He adds that because the case would have been tried in Seattle, which felt stung after Boeing moved its headquarters to Chicago on Sept. 1, 2001, company lawyers feared a vindictive jury. Instead, it was willing to accept the settlement — which Bain says is totally covered by the company’s insurance policies.
If the Boeing lawsuit had gone to trial, jurors would have heard a story that begins around 19%, when Boeing was facing a strategic crisis because of shrinking defense business. Condit had a choice: either acquire a bigger share of the market or drop out of it. Since defense provided stable income to offset roller-coaster commercial plane sales, Condit chose to grow, buying Rockwell Aerospace & Defense in August, then striking the McDonnell deal just four months later. The ambitious chairman, always admired more for his strategic shrewdness than his operational expertise, was hoping to seal his legacy. But this bold expansion came at a time when the company faced mounting internal problems.
As the global economy emerged from recession in the early 1990s, aerospace companies enjoyed skyrocketing orders, which rose worldwide from 15 aircraft in 1993 to 898 in 1996. But Boeing’s antiquated parts-tracking system couldn’t keep up with the increased production volume. And supply problems prevented it from getting enough seats and electronic gear on time.
This problem was compounded in late 1994 when Boeing realized that rival Airbus Industrie, the European consortium, was undercutting it on price, thanks to lower manufacturing costs and government subsidies. By that year, Airbus had grabbed 30% of the global jet-plane market — up from less than 3% two decades earlier. It was a potentially devastating development, since lost customers in the airliner industry are hard to win back after they’ve spent a fortune training pilots and mechanics on rivals’ equipment.
Boeing was forced to knock down costs across the board. It made early-retirement offers to 9,500 workers in 1995, slashing its staff of veteran mechanics and engineers. Execs also rolled out a bug-ridden new computer system for tracking parts, known by the unwieldy name of Define & Control Airplane Configuration/Manufacturing Resource Management (DCAC). As a consultant pointed out in a report to factory execs in the summer of 1997. the prospect of doubling production rates in the face of such change was like attempting “a four-and-a-half somersault off a 50-foot board into a pail of water.”
By early 1997, warning signs were everywhere that Boeing’s overheated factories were boiling over. On Dec. 2, 1996, Deloitte & Touche had alerted the board’s audit committee “that production performance metrics began to trend unfavorably — overtime, parts shortages, rework, defective parts, and out-of-sequence work increased.” About a dozen alarmed managers at the company’s giant Renten (Wash.) facility met in May for a “reality check” meeting. They calculated that Boeing’s production system was more than $1 billion over initial cost projections. One manager taking notes at the get-together concluded that “we have a real financial crisis on our hands” with “no relief in sight.
While top execs did acknowledge publicly that the company was having some production problems in the first half of 1997, they consistently underplayed the issue. In fact, the company developed a Production Issues Communication Plan on Mar. 27, 1997, to stave off “focusfed] media attention on the issue of our ability to meet customer commitments.” The document, among other things, coached executives on how they should respond to reporters’ questions, according to plaintiffs’ lawyer Steve W. Berman, who brought the fraud suit against Boeing. Talking to reporters after the company’s annual meeting in April, 1997, Condit said that the ramp-up in demand “has resulted in a near-term decline in productivity at company faculties and some supplier locations.” With characteristic confidence, he said that the first quarter’s inefficiencies “would not be repeated during the remaining quarters of the year” and that the company was not having “systematic” assembly-line malfunctions.
But already many managers were predicting late deliveries-a catastrophe that aircraft makers avoid at all costs, since it triggers enormous late fees and wreaks havoc on customers’ business plans. As Boeing’s Gary Scott, vice-president for 737/757 production, wrote in a memo on Mar. 20, 1997: “Late deliveries due to late [engineering] releases are becoming a significant problem.” As the weeks wore on, the delays grew worse. On June 27, three days before the end of the second quarter, about a dozen Boeing commercial airplane executives met in a windowless meeting room in Renton for their second-quarter financial plan review. They learned that at least 15 aircraft would probably miss their delivery dates, according to the plaintiffs’ complaint.
At this point — about a month before the McDonnell merger vote — Boeing should have started sharing some of the bad news with investors, according to Smith and other independent accounting experts. Under special aerospace industry rules that are part of generally accepted accounting principles (GAAP), companies are required to accrue reserves for probable late-delivery penalties and disclose them in the quarter they become known. Additionally, “abnormal” costs must be recognized in the quarter in which they are incurred. Expenses stemming from the company’s production problems in the first half of 1997 “should have been booked in the quarters they were incurred and reflected in the profit numbers for those quarters,” says Eugene A. Imhoff Jr., an independent expert on program accounting at the University of Michigan.
But Boeing never did so. On July 21, 1997, it reported second-quarter earnings of $334 million — a number that understated its production costs, the suit charges, by 3292 million. What’s more, investors still had no idea that the company had run up $253 million in unexpected costs in the first quarter or that it would soon would be facing more than $200 million in late-delivery penalties.
Boeing says it would have been a violation of GAAP to recognize any increased production charges in the first half of 1997. Of the 15 planes viewed as potential late deliveries on June 27, it says that “nearly all” snipped on time. Noting that costs always increase sharply during growth periods, lawyer Bain says the unplanned escalation in expenses that the company suffered in early 1997 was consistent with historic patterns. Therefore, he argues, they were not “abnormal”and did not meet the test, under GAAP, for an immediate write-off. Boeing argues that nothing “abnormal” happened until it had to halt its production lines on Oct. 3. The lawsuit was primarily “a hindsight dispute about the timing of a write-off,” says Ronald W. Stahlschmidt, a program-accounting expert hired to be a company witness.
But a Deloitte working paper written in the second half of 1997 offers evidence that some members of the auditing team took the opposite view: that the cost overruns should have been charged in the first half of the year. In the memo, Deloitte called the production disruptions in the first and second quarters “so abnormal as to require treatment as current-period charges.” The auditor then said that Boeing’s decrease in third-quarter earnings was “retroactively applied” to the first and second quarters of 1997. Boeing says that “the work paper’s reference to “retroactive’ does not suggest that Boeing should have restated its first- or second-quarter 1997 earnings. It means only that, in taking a charge correctly in the third quarter, Boeing estimated that charge by reference to year-to-date data.”
The 1997 assembly-line meltdown afflicted every type of plane Boeing made. But it created a particular problem for the prestigious 777 line, according to former Boeing employees. To understand why, it’s necessary to look closely at the unusual accounting system used by the aerospace industry. The program-accounting method was developed by Boeing and others in the industry in the 1960s to deal with a central problem: most of the costs of creating a new plane are incurred in its early years, while revenues roll in during later years.
To smooth out costs and revenues, aerospace companies are allowed to average them over the entire duration of an airplane “program” — usually defined as an initial production run of 400 aircraft. They do this by establishing a projected profit margin up front — say, 10% for the entire line. This number, which is continuously updated, is based on Boeing’s estimates of the average costs and revenues over the remainder of the program. Every quarter, the “profit” the company reports is based on these projected averages, rather than its actual costs or revenues. The whole system is built on faith that aerospace companies can come up with accurate long-term forecasts. To a degree unmatched in nearly any other industry, aerospace companies’ disclosures are based on their own private estimates. In this way, companies such as Boeing can absorb the ups and downs that characterize the industry.
But that comes at a considerable price: little transparency for investors. “The problem with program accounting is that it is virtually impossible to audit,” says Lynn E. Turner, former chief accountant at the SEC and now director of the Center for Quality Financial Reporting at Colorado State University. “No one really knows whether the company will produce as many planes as [are] needed to recover the costs.”
To mitigate this problem, the rules require companies to take an immediate charge as soon as they have evidence that a line’s long-term profit margin will disappear — or, in industry lingo, that the program will be in a “forward-loss” position. And that’s just what appears to have been happening to the 777 line in early 1997. Launched with great fanfare in the early 1990s, it had a development budget of $5 billion to $7 billion for initial design, production tooling, and flight-testing. By 1995, it had quietly overrun this budget by nearly 100%, according to two former high-ranking Boeing managers.
The prospect of a forward loss in the 777 was galling to Boeing, since it was the newest model — the plane that boasted the most advanced technology, that was to drive the company’s performance in the next decade, and that carried Condit’s reputation. Downgrading the 777’s forecast would have been not only an embarrassment but also a threat to the merger. So it was bad news when, in its 1996 audit, Deloitte said the “low gross margin” projected for the current block of 777 aircraft risked a decline in “cost performance that would place the program in a forward-loss position.”
To avoid this humiliation, the company allegedly started to shift monetary reserves from healthier aircraft programs to keep the 777 on budget, according to the complaint and two former high-ranking executives. These are funds that would accumulate when Boeing overestimated the costs for some plane lines. Officers established “management reserves” to pay for, as current corporate Controller James M. Bell put it, “unknown unknowns” — unexpected expenses that historically arise because of the complexity of airplane construction.
While the establishment of these management reserves is perfectly legal, it is a violation of GAAP to shift money from one program to another. Nevertheless, a handwritten note from a Boeing employee dating from May or June, 1997, said the company had borrowed from other divisions to boost the 777. “Much of the reserve balance used to cover performance was generated by other divisions and spent on the 777 division,” it ran. Specifically, the company drew on reserves from the profitable 767 line after the reserve established for the 777 “was overrun” in early 1997, says one former Boeing manager.
Boeing vehemently denies it shifted reserves. The handwritten 1997 note “did not mean what the plaintiffs’ lawyers suggested it meant,” says Douglas Greene, an outside lawyer at Seattle’s Perkins Coie who represented Boeing in the securities-fraud litigation. Boeing did not, and does not, have any “off-balance-sheet,” “cookie-jar,” or “general contingency” reserves, says Judith Munlberg, vice-president for communications. “All reserves at Boeing are related to specific items.”
Another method Boeing allegedly used to stave off a 777 write-off was exaggerating the effectiveness of some of the cost-savings initiatives it had launched in the mid1990s. Under the flexible rules of program accounting, plane makers are permitted to make projections about efficiency efforts and start tabulating the benefits immediately — even if, as a practical matter, the initiative isn’t yet working.
But this practice can run afoul of the law, Berman claims, if it is intended to prevent a particular airplane program from getting into a forward-loss position, which would require the company to take a current charge against earnings. And that’s just what he says was happening in 1997.
According to the plaintiffs’ complaint, Boeing “arbitrarily manipulate[d] cost-savings figures upwards in order to keep the 777 gross profit estimates from falling into a [forward-] loss position” during the second quarter of 1997. The complaint quotes a Deloitte working paper that says Boeing’s managers admitted the second-quarter cost-reduction figures were “a plug” to keep the 777 profit margins on target A plug is a commonly used accounting term for a number artificially generated to produce a desired result.
It is unclear which particular savings initiatives were used to create the alleged plug. As part of its plan to catch up to Airbus, Boeing had several efficiency programs under way. But former employees assert that the estimated savings from the DCAC parts-tracking initiative, for one, were exaggerated. Launched in 1994, the program cost a total of $1 billion, they say. Boeing estimated it would pay for itself in two years — and cut the expense of building a plane by at least 25%.
Problem was, the program cost far more than had been anticipated. Almost from the start, the DCAC software was riddled with bugs. One exec involved in DCAC estimates that overruns reached hundreds of millions of dollars. An internal audit in the third quarter of 1997 revealed that estimated DCAC cost savings were being “arbitrarily predetermined” to show more of a savings benefit than actually existed. When production managers at Boeing’s Wichita assembly plant were shown the estimated savings they were expected to meet in March, 1997, “no one would sign off on these numbers” because the savings benefit appeared unrealistic, according to a report written by internal auditor Susan Parker. Even without the signatures, the DCAC savings figures were included in that year’s business plan, the report states. Boeing declined to discuss in detail the allegations that it used bogus cost savings to prop up the 777. “We are limited in the amount of things we want to say about it for competitive and proprietary reasons,” says Muhlberg. She added that “Boeing believes that its DCAC/MRM … cost-savings estimates were reasonable when made.”
Boeing’s efforts paid off: The company never declared a forward loss on the 777 in 1997 — and has not done so at any time since. Does that mean that the line met the original profitability targets? Not necessarily. Very quietly, Boeing has bought itself time to resolve the line’s problems by increasing the number of planes in the 777 program. The initial block of 400 units has been extended twice — first to 500 planes, and then later to 600.
Under the rules of program accounting, these maneuvers directly improve the 777’s reported profitability by lowering the percentage of the original development costs that are charged each quarter. Just extending the block from 500 to 600 aircraft reduced deferred production costs for the 777 program alone by $8 million per plane, according to Todd Ernst, a Prudential Securities Inc. aerospace analyst. He calculated that this saved Boeing $68 million a quarter and boosted quarterly earnings by up to 6¢ a share for 2001. “The magnitude of the impact struck me,” he said. “It was a big change in the cost of the airplane.”
A neat trick — and one that is perfectly legal under the GAAP rules governing program accounting. The company didn’t have to announce this important development with a big press conference. To the contrary, the news was buried in a cryptic sentence deep in Boeing’s 2000 10-K. For its part, Boeing claims that programs are extended not to defer production costs but to reflect more sales than originally anticipated. When Boeing has firm sales contracts or high “certainty that the market is going to absorb more airplanes than we have in the current [program], we extend it,” says Controller Bell.
No doubt other corporations would love to have such financial flexibility. The wonders of program accounting give Boeing more ability to paper over any short-term disasters than is enjoyed in nearly any other industry. As a result of this situation, investors need to be able to place an unusually high degree of faith in the company’s managers. Boeing says that it has always earned shareholders’ confidence with its rigorous cost- and sales-estimation process. The business planning process in 1997, for example, was “methodical and analytic,” the company wrote to BusinessWeek. “It represented Boeing’s half-century of experience in manufacturing commercial airplanes. Hundreds of industrial engineers and accountants worked as separate teams to estimate the thousands of separate cost items in each program.”
That may well be the case. But if there’s a moral to this story, it’s that when the stakes are high, the temptations to take advantage of any flexibility in accounting standards can be great. “If you can prove that subjective judgments are dead wrong to the tune that Boeing is willing to cough up $92 million, they must really have been exaggerating their hopes for the future,” according to Imhoff, the University of Michigan program-accounting expert. The ease with which executives have the capacity to manipulate program accounting is one reason why the SEC told the American Institute of Certified Public Accountants in the early 1980s that it would not permit the extension of the system to other industries, according to Turner, the former SEC accounting chief.
After the 1997 meltdown, Condit nearly lost his job and Chief Financial Officer Givan was replaced in the position by Deborah C. Hopkins. To regain credibility with the markets, the company took definite steps in an effort to increase its own financial transparency. Former company officials say that Hopkins and Stonecipher toyed with the idea of dropping program accounting altogether. The two Boeing executives complained that the system confused investors and didn’t provide managers with sufficiently detailed information about the costs involved in manufacturing an aircraft. “You cannot reduce the cost of a wing if you don’t know where you are starting,” Stonecipher complained in an April, 1999, interview with CFO magazine.
That idea was abandoned. But in 1999, the company did start providing investors with supplemental information based on standard unit accounting. For example, it now supplies a line item in its reports indicating what the commercial airplane division’s quarterly earnings would be on a traditional unit basis.
This information, in theory, should make it harder for the company to mask a production crisis ever again. But analysts complain that the direct operating income of the commercial aircraft division is mixed in with earnings from its pension fund and leasing business. And those items, which are only disclosed annually, can be significant. In 2001, pension-fund income accounted for about $785 million, or 18.6% of Boeing’s pretax earnings. “A whole mishmash of other operating items get thrown into this unit-accounting line item,” complains Robert Friedman, aerospace analyst at Standard & Poor’s. “It definitely clouds the quality of earnings picture.”
So while Boeing is not as big a mystery today as it was in 1997, it is still much harder to evaluate than most companies. Its accounting methods are none too popular with the professionals charged with decoding Boeing’s books. “You can drive a truck through what’s GAAP in aircraft manufacturing,” says Heidi Wood, an aerospace analyst at Morgan Stanley Dean Witter & Co. “I think everybody has grown weary of program accounting for a while.”
At the moment, though, there are no plans to get rid of the system. That’s not a bad thing for shareholders to keep in mind. At a time when investors are seeking the maximum in transparency, Boeing is not even close to that standard.
Boeing still uses controversial program accounting that lets it offset steep upfront costs with distant payoffs
Boeing insists it never misled shareholders and that it had no duty to disclose the cost overruns in early 1997
Welcome reform: Since 1999, Boeing provides investors extra information based on standard unit accounting
Each mental intervention is based on the evidence gathered during the initial interview with the patient; each patient's therapy begins with a thorough medical and mental health evaluation, the incorporation of trust, and a dialogue of past mental health history, substance misuse history, family mental health history, and so forth. The evaluation of the patient in this case was documented, and a diagnostic impression was formed based on the information obtained from the patient during the evaluation. A therapy strategy was devised when the case was developed. The patient is a 7-year-old Caucasian boy who was scheduled for an initial screening for a mood disorder after her pediatrician recommended that she consult a psychiatrist. At this time, the patient is not taking any medications. DDAVP PO was given to the patient, but it was stopped since it was ineffective.
HPI
HPI: R.C a 7-year-old White male who was referred to a psychiatrist for evaluation after several treatments and efforts by his teacher to help him with his mood. According to patient's mother during the interview, the mother said that the pediatrician placed patient on DDAVP which did not help patient. Mother did not list dose of medication or frequency. During the interview, patient states that he feels worried most time. Patient said " I am worried about everything". Patient admits to bad dreams and that he dreams a lot that he can't find his brother and mom. When asked if patient feels lost. Patient responding saying " I worry about my mom and brother when I am alone". Patient went further to state "People in school don't like me. They call me smelly and calls me names". Patient said that his mom said his school mates calls him
those names because patient does not take her baths. Patient expressed that he is sad about it. Patient said sometimes he will have accidents at night. Patient also states that his school mates his school mates don't know how it feels when your father can't come back home and that he worried what if his mom does not come home. Patient states that his teacher also picks on him in class. His teacher was telling him to sit down and focus. Patients admit to harming other by saying" I have thrown book at Billy". Denies ever causing harm to himself or any intention to harm himself.
When the mother was interviewed, the mother expressed her concern that patient is anxious and worry about silly things like his is going to die, that the mom loves his brother more than she loves him, that the mom won't pick him up in school. Mother expressed that he has a difficult time going to sleep, learning difficulty, gets in trouble in school, throws things around the house, wants his light on at night and doors open, has difficult time going to sleep, claims stomach upset just to be sent home from school, almost daily. He won't eat and has lost some weight. lost 3 pounds in the last 3 weeks. Mother explained that he wets the bed at night. That the pediatrician referred them to the Psychiatrist and has prescribed him DDVAP, but the medication doesn't seem to help. Mother expressed that Rev father was killed in the war but she thought Rev was too young to know about death, so she didn't tell him his father is late. Mother feels guilty about not disclosing the death of Rev's father to him and said it was all her fault that Rev functions this way.
Mental Status Examination
Patient appeared stated age, no apparent distress on arrival and during the session. Patient and baby appears well nourished, well groomed. Well dressed and clean. Patient was cooperative, not fidgeting, makes good eye contact and able to sit still. Patient appears to be anxious and worried Affect was full range, somewhat constricted and often sad. Able to stay still. No abnormal movement noted. Gait steady and posture upright. Patient was coherent but not very logical due to worry. No acute psychosis or mood symptoms. No delusions or paranoid behavior noted. Patient has some intrusive thoughts. Patient’s speech was normal rate, rhythm volume and clear. Patient does not feel like she will get better. She had a good judgment and recognized what she needs to be done to care for her baby. Patient was attentive to the provider and attentive to the baby’s needs while she learn. Alert and oriented times 4. Memory both long and short term was intact. Patient denies suicide ideation. Patient admits having intrusive thoughts of hurting baby but patient finds this thoughts upsetting and denies intent. Patient states she removes herself in situation that can cause harm to baby.
Differential Diagnoses
Adjustment Disorder: "Adjustment disorder is a maladaptive response to recognized psychosocial stressors or life changes that is characterized by obsession with the stressor and failure to adapt." Within three months of the initiation of a specific stressor, disorder is defined as the appearance of emotional or behavioral symptoms in reaction to the stressor. Adjustment can result from expected or unexpected events, and it can lead to disorder, causing an individual to feel confused, worried, anxious and disoriented (disoriented), preventing him from going about his normal routine. Separation, dissolution of marriage, the termination of a long-term relationship unexpected death of a loved one, the loss of a career, being cheated on by a partner or spouse, being the victim of a sexual assault are all examples of stressful events that can result to adjustment disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) must be completed within three months after the commencement of the stressor or stressors. In addition, one or both of the following conditions must be fulfilled: Clinically significant distress is defined as distress that is out of proportion to the predicted stressor reactions and symptoms. They cause a lot of pain and make it difficult to function (American Psychiatric Association, 2013).
Generalized Anxiety Disorder: Excessive anxiety and worry regarding a number of events or activities, happening more days than not for at least 6 months (such as work or school performance). GAD (generalized anxiety disorder) is a mental health issue that affects both children and adolescents. A youngster with GAD experiences a lot of worry and terror for no apparent reason. Worry may be excessive in comparison to the situation. Physical appearance, prior habits, social acceptance, family difficulties, failing to fulfill parents' expectations, personal abilities, and academic success are all common concerns for children and teens with GAD. Generalized Anxiety Disorder is a natural stress response that, in certain cases, can be beneficial
It can alert us to potential risks and help us plan and pay attention. Excessive dread or anxiety characterizes anxiety disorders, as opposed to normal feelings of apprehension or anxiety. Anxiety disorders are the most prevalent mental illnesses, affecting almost one-third of all adults at some point in their lives. Diagnostic Criteria for Generalized Anxiety Disorder (GAD) in the DSM-5: Excessive anxiety and worry (apprehensive expectancy) about a number of events or activities, occurring more days than not for at least 6 months (such as work or school performance), the individual has difficulty controlling his or her anxiety, and three (or more) of the following six symptoms are linked to anxiety and worry: Being easily fatigued, having difficulty concentrating, or having your mind go blank are all indicators of restlessness or agitation. Irritability manifests itself in the form of irritability, muscle tension, and sleep difficulties (American Psychiatric Association, 2013).
Dysthymic Disorder: Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years. Presence while depressed of two or more of the following: Poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decision, feelings of hopelessness. The disturbance is not caused by a substance's direct physiological effects (e.g., a drug of abuse or a medicine) or a general medical condition. Clinically substantial distress or impairment in crucial areas of functioning are caused by the symptoms. Although dysthymia was once thought to be less severe than major depression, its implications are now widely acknowledged to be serious, including significant functional impairment, increased morbidity from physical disease, and an increased risk of suicide. To determine a diagnosis of Dysthymic Disorder, the DSM-5 provides the following criteria. During the 2 years period, the person must have five or more symptoms, with at least one of them being either (1) sad mood or (2) lack of interest or pleasure. Changes in energy level, depressed mood most of the day, nearly every day, decrease or increase in appetite nearly every day, poor self-esteem, anxiety, isolation, appetite change, forgetfulness, not completing assigned chores at work or school, guilt, and loss of energy are all listed in the DSM-5 (American Psychiatric Association, 2013).
Reflection
Every mental intervention is determined by the information collected during the initial conversation with the client; every client's therapy starts with a comprehensive medical and behavioral health examination, the creation of trust, and a discussion of previous mental health history, substance abuse history, family mental health history, and so on. Individuals with whom they had connections that comprised effective communication, cultural awareness, and the absence of compulsion were considered as trustworthy (Sadock et al., 2014). One thing I might have done differently as a PMHNP is to meet the patient first, establish a therapeutic relationship, ask the young patient about his relationship with his parents, and then ask questions unrelated to the scheduled visit, which would help to create a welcoming atmosphere. Ask openended inquiries on the patient's personality, ailment, or personality without appearing to have a bias. Inquire about the patient's sexual orientation and preferred method of communication. Cultural competency includes elements such as trust, respect for diversity, respect for religion, equity, fairness, and social justice, which must all be considered during any interview or encounter between a healthcare practitioner and a patient (Sadock et al., 2014). When I interview a patient about their mental illness symptoms, I look at how they look, speak, and act to determine if there are any clues that could explain their symptoms.
The patient will begin individual supportive therapy then advance to family and peer group supportive therapy depending on level of improvement. The patient’s mother will receive an educational pamphlet, as well as assignments and a follow-up consultation, on themes that will aid in the healing and coping process. Patient will be started on fluoxetine (Prozac). An initial dose of 10 mg/day then increased to 20 mg/day after 1 week. Education and side effects of medication was provided for mother and son. Bedwetting can be avoided by limiting how much a child drinks in the evening, avoiding caffeinated meals and beverages, and promoting regular toilet usage throughout the day. Mother was told to wake the patient up at night to urinate and to make sure the patient's clothing were changed before going to school in the morning. Personal hygiene assistance should be provided to the patient. In case of emergency, the provider provided patient with helpful phone numbers: 911 for emergencies and the Client's Crisis Line. Reports from doctors and therapists were evaluated for mutual and collaborative understanding and for continuity of care. Patient’s mother was educated and was advised to call their primary care physician or go to the nearest emergency department if they had any questions or concerns about the development of any undesirable or unexpected outcome or side effects. Every 30 days, patient must return to psych tele-appointments for continuity of care and for provider to monitor progress and outcome of treatment but patient will return a week after starting Prozac for adjustment of dosing and to monitor improvement.
July 1, 2023
Introduction
Each mental intervention is based on the evidence gathered during the initial interview with the patient; each patient's therapy begins with a thorough medical and mental health evaluation, the incorporation of trust, and a dialogue of past mental health history, substance misuse history, family mental health history, and so forth. The evaluation of the patient in this case was documented, and a diagnostic impression was formed based on the information obtained from the patient during the evaluation. A therapy strategy was devised when the case was developed. The patient is a 7-year-old Caucasian boy who was scheduled for an initial screening for a mood disorder after her pediatrician recommended that she consult a psychiatrist. At this time, the patient is not taking any medications. DDAVP PO was given to the patient, but it was stopped since it was ineffective.
HPI
HPI: R.C a 7-year-old White male who was referred to a psychiatrist for evaluation after several treatments and efforts by his teacher to help him with his mood. According to patient's mother during the interview, the mother said that the pediatrician placed patient on DDAVP which did not help patient. Mother did not list dose of medication or frequency. During the interview, patient states that he feels worried most time. Patient said " I am worried about everything". Patient admits to bad dreams and that he dreams a lot that he can't find his brother and mom. When asked if patient feels lost. Patient responding saying " I worry about my mom and brother when I am alone". Patient went further to state "People in school don't like me. They call me smelly and calls me names". Patient said that his mom said his school mates calls him
those names because patient does not take her baths. Patient expressed that he is sad about it. Patient said sometimes he will have accidents at night. Patient also states that his school mates his school mates don't know how it feels when your father can't come back home and that he worried what if his mom does not come home. Patient states that his teacher also picks on him in class. His teacher was telling him to sit down and focus. Patients admit to harming other by saying" I have thrown book at Billy". Denies ever causing harm to himself or any intention to harm himself.
When the mother was interviewed, the mother expressed her concern that patient is anxious and worry about silly things like his is going to die, that the mom loves his brother more than she loves him, that the mom won't pick him up in school. Mother expressed that he has a difficult time going to sleep, learning difficulty, gets in trouble in school, throws things around the house, wants his light on at night and doors open, has difficult time going to sleep, claims stomach upset just to be sent home from school, almost daily. He won't eat and has lost some weight. lost 3 pounds in the last 3 weeks. Mother explained that he wets the bed at night. That the pediatrician referred them to the Psychiatrist and has prescribed him DDVAP, but the medication doesn't seem to help. Mother expressed that Rev father was killed in the war but she thought Rev was too young to know about death, so she didn't tell him his father is late. Mother feels guilty about not disclosing the death of Rev's father to him and said it was all her fault that Rev functions this way.
Mental Status Examination
Patient appeared stated age, no apparent distress on arrival and during the session. Patient and baby appears well nourished, well groomed. Well dressed and clean. Patient was cooperative, not fidgeting, makes good eye contact and able to sit still. Patient appears to be anxious and worried Affect was full range, somewhat constricted and often sad. Able to stay still. No abnormal movement noted. Gait steady and posture upright. Patient was coherent but not very logical due to worry. No acute psychosis or mood symptoms. No delusions or paranoid behavior noted. Patient has some intrusive thoughts. Patient’s speech was normal rate, rhythm volume and clear. Patient does not feel like she will get better. She had a good judgment and recognized what she needs to be done to care for her baby. Patient was attentive to the provider and attentive to the baby’s needs while she learn. Alert and oriented times 4. Memory both long and short term was intact. Patient denies suicide ideation. Patient admits having intrusive thoughts of hurting baby but patient finds this thoughts upsetting and denies intent. Patient states she removes herself in situation that can cause harm to baby.
Differential Diagnoses
Adjustment Disorder: "Adjustment disorder is a maladaptive response to recognized psychosocial stressors or life changes that is characterized by obsession with the stressor and failure to adapt." Within three months of the initiation of a specific stressor, disorder is defined as the appearance of emotional or behavioral symptoms in reaction to the stressor. Adjustment can result from expected or unexpected events, and it can lead to disorder, causing an individual to feel confused, worried, anxious and disoriented (disoriented), preventing him from going about his normal routine. Separation, dissolution of marriage, the termination of a long-term relationship unexpected death of a loved one, the loss of a career, being cheated on by a partner or spouse, being the victim of a sexual assault are all examples of stressful events that can result to adjustment disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) must be completed within three months after the commencement of the stressor or stressors. In addition, one or both of the following conditions must be fulfilled: Clinically significant distress is defined as distress that is out of proportion to the predicted stressor reactions and symptoms. They cause a lot of pain and make it difficult to function (American Psychiatric Association, 2013).
Generalized Anxiety Disorder: Excessive anxiety and worry regarding a number of events or activities, happening more days than not for at least 6 months (such as work or school performance). GAD (generalized anxiety disorder) is a mental health issue that affects both children and adolescents. A youngster with GAD experiences a lot of worry and terror for no apparent reason. Worry may be excessive in comparison to the situation. Physical appearance, prior habits, social acceptance, family difficulties, failing to fulfill parents' expectations, personal abilities, and academic success are all common concerns for children and teens with GAD. Generalized Anxiety Disorder is a natural stress response that, in certain cases, can be beneficial
It can alert us to potential risks and help us plan and pay attention. Excessive dread or anxiety characterizes anxiety disorders, as opposed to normal feelings of apprehension or anxiety. Anxiety disorders are the most prevalent mental illnesses, affecting almost one-third of all adults at some point in their lives. Diagnostic Criteria for Generalized Anxiety Disorder (GAD) in the DSM-5: Excessive anxiety and worry (apprehensive expectancy) about a number of events or activities, occurring more days than not for at least 6 months (such as work or school performance), the individual has difficulty controlling his or her anxiety, and three (or more) of the following six symptoms are linked to anxiety and worry: Being easily fatigued, having difficulty concentrating, or having your mind go blank are all indicators of restlessness or agitation. Irritability manifests itself in the form of irritability, muscle tension, and sleep difficulties (American Psychiatric Association, 2013).
Dysthymic Disorder: Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years. Presence while depressed of two or more of the following: Poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decision, feelings of hopelessness. The disturbance is not caused by a substance's direct physiological effects (e.g., a drug of abuse or a medicine) or a general medical condition. Clinically substantial distress or impairment in crucial areas of functioning are caused by the symptoms. Although dysthymia was once thought to be less severe than major depression, its implications are now widely acknowledged to be serious, including significant functional impairment, increased morbidity from physical disease, and an increased risk of suicide. To determine a diagnosis of Dysthymic Disorder, the DSM-5 provides the following criteria. During the 2 years period, the person must have five or more symptoms, with at least one of them being either (1) sad mood or (2) lack of interest or pleasure. Changes in energy level, depressed mood most of the day, nearly every day, decrease or increase in appetite nearly every day, poor self-esteem, anxiety, isolation, appetite change, forgetfulness, not completing assigned chores at work or school, guilt, and loss of energy are all listed in the DSM-5 (American Psychiatric Association, 2013).
Reflection
Every mental intervention is determined by the information collected during the initial conversation with the client; every client's therapy starts with a comprehensive medical and behavioral health examination, the creation of trust, and a discussion of previous mental health history, substance abuse history, family mental health history, and so on. Individuals with whom they had connections that comprised effective communication, cultural awareness, and the absence of compulsion were considered as trustworthy (Sadock et al., 2014). One thing I might have done differently as a PMHNP is to meet the patient first, establish a therapeutic relationship, ask the young patient about his relationship with his parents, and then ask questions unrelated to the scheduled visit, which would help to create a welcoming atmosphere. Ask openended inquiries on the patient's personality, ailment, or personality without appearing to have a bias. Inquire about the patient's sexual orientation and preferred method of communication. Cultural competency includes elements such as trust, respect for diversity, respect for religion, equity, fairness, and social justice, which must all be considered during any interview or encounter between a healthcare practitioner and a patient (Sadock et al., 2014). When I interview a patient about their mental illness symptoms, I look at how they look, speak, and act to determine if there are any clues that could explain their symptoms.
The patient will begin individual supportive therapy then advance to family and peer group supportive therapy depending on level of improvement. The patient’s mother will receive an educational pamphlet, as well as assignments and a follow-up consultation, on themes that will aid in the healing and coping process. Patient will be started on fluoxetine (Prozac). An initial dose of 10 mg/day then increased to 20 mg/day after 1 week. Education and side effects of medication was provided for mother and son. Bedwetting can be avoided by limiting how much a child drinks in the evening, avoiding caffeinated meals and beverages, and promoting regular toilet usage throughout the day. Mother was told to wake the patient up at night to urinate and to make sure the patient's clothing were changed before going to school in the morning. Personal hygiene assistance should be provided to the patient. In case of emergency, the provider provided patient with helpful phone numbers: 911 for emergencies and the Client's Crisis Line. Reports from doctors and therapists were evaluated for mutual and collaborative understanding and for continuity of care. Patient’s mother was educated and was advised to call their primary care physician or go to the nearest emergency department if they had any questions or concerns about the development of any undesirable or unexpected outcome or side effects. Every 30 days, patient must return to psych tele-appointments for continuity of care and for provider to monitor progress and outcome of treatment but patient will return a week after starting Prozac for adjustment of dosing and to monitor improvement.
July 1, 2023
Introduction
Each mental intervention is based on the evidence gathered during the initial interview with the patient; each patient's therapy begins with a thorough medical and mental health evaluation, the incorporation of trust, and a dialogue of past mental health history, substance misuse history, family mental health history, and so forth. The evaluation of the patient in this case was documented, and a diagnostic impression was formed based on the information obtained from the patient during the evaluation. A therapy strategy was devised when the case was developed. The patient is a 7-year-old Caucasian boy who was scheduled for an initial screening for a mood disorder after her pediatrician recommended that she consult a psychiatrist. At this time, the patient is not taking any medications. DDAVP PO was given to the patient, but it was stopped since it was ineffective.
HPI
HPI: R.C a 7-year-old White male who was referred to a psychiatrist for evaluation after several treatments and efforts by his teacher to help him with his mood. According to patient's mother during the interview, the mother said that the pediatrician placed patient on DDAVP which did not help patient. Mother did not list dose of medication or frequency. During the interview, patient states that he feels worried most time. Patient said " I am worried about everything". Patient admits to bad dreams and that he dreams a lot that he can't find his brother and mom. When asked if patient feels lost. Patient responding saying " I worry about my mom and brother when I am alone". Patient went further to state "People in school don't like me. They call me smelly and calls me names". Patient said that his mom said his school mates calls him
those names because patient does not take her baths. Patient expressed that he is sad about it. Patient said sometimes he will have accidents at night. Patient also states that his school mates his school mates don't know how it feels when your father can't come back home and that he worried what if his mom does not come home. Patient states that his teacher also picks on him in class. His teacher was telling him to sit down and focus. Patients admit to harming other by saying" I have thrown book at Billy". Denies ever causing harm to himself or any intention to harm himself.
When the mother was interviewed, the mother expressed her concern that patient is anxious and worry about silly things like his is going to die, that the mom loves his brother more than she loves him, that the mom won't pick him up in school. Mother expressed that he has a difficult time going to sleep, learning difficulty, gets in trouble in school, throws things around the house, wants his light on at night and doors open, has difficult time going to sleep, claims stomach upset just to be sent home from school, almost daily. He won't eat and has lost some weight. lost 3 pounds in the last 3 weeks. Mother explained that he wets the bed at night. That the pediatrician referred them to the Psychiatrist and has prescribed him DDVAP, but the medication doesn't seem to help. Mother expressed that Rev father was killed in the war but she thought Rev was too young to know about death, so she didn't tell him his father is late. Mother feels guilty about not disclosing the death of Rev's father to him and said it was all her fault that Rev functions this way.
Mental Status Examination
Patient appeared stated age, no apparent distress on arrival and during the session. Patient and baby appears well nourished, well groomed. Well dressed and clean. Patient was cooperative, not fidgeting, makes good eye contact and able to sit still. Patient appears to be anxious and worried Affect was full range, somewhat constricted and often sad. Able to stay still. No abnormal movement noted. Gait steady and posture upright. Patient was coherent but not very logical due to worry. No acute psychosis or mood symptoms. No delusions or paranoid behavior noted. Patient has some intrusive thoughts. Patient’s speech was normal rate, rhythm volume and clear. Patient does not feel like she will get better. She had a good judgment and recognized what she needs to be done to care for her baby. Patient was attentive to the provider and attentive to the baby’s needs while she learn. Alert and oriented times 4. Memory both long and short term was intact. Patient denies suicide ideation. Patient admits having intrusive thoughts of hurting baby but patient finds this thoughts upsetting and denies intent. Patient states she removes herself in situation that can cause harm to baby.
Differential Diagnoses
Adjustment Disorder: "Adjustment disorder is a maladaptive response to recognized psychosocial stressors or life changes that is characterized by obsession with the stressor and failure to adapt." Within three months of the initiation of a specific stressor, disorder is defined as the appearance of emotional or behavioral symptoms in reaction to the stressor. Adjustment can result from expected or unexpected events, and it can lead to disorder, causing an individual to feel confused, worried, anxious and disoriented (disoriented), preventing him from going about his normal routine. Separation, dissolution of marriage, the termination of a long-term relationship unexpected death of a loved one, the loss of a career, being cheated on by a partner or spouse, being the victim of a sexual assault are all examples of stressful events that can result to adjustment disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) must be completed within three months after the commencement of the stressor or stressors. In addition, one or both of the following conditions must be fulfilled: Clinically significant distress is defined as distress that is out of proportion to the predicted stressor reactions and symptoms. They cause a lot of pain and make it difficult to function (American Psychiatric Association, 2013).
Generalized Anxiety Disorder: Excessive anxiety and worry regarding a number of events or activities, happening more days than not for at least 6 months (such as work or school performance). GAD (generalized anxiety disorder) is a mental health issue that affects both children and adolescents. A youngster with GAD experiences a lot of worry and terror for no apparent reason. Worry may be excessive in comparison to the situation. Physical appearance, prior habits, social acceptance, family difficulties, failing to fulfill parents' expectations, personal abilities, and academic success are all common concerns for children and teens with GAD. Generalized Anxiety Disorder is a natural stress response that, in certain cases, can be beneficial
It can alert us to potential risks and help us plan and pay attention. Excessive dread or anxiety characterizes anxiety disorders, as opposed to normal feelings of apprehension or anxiety. Anxiety disorders are the most prevalent mental illnesses, affecting almost one-third of all adults at some point in their lives. Diagnostic Criteria for Generalized Anxiety Disorder (GAD) in the DSM-5: Excessive anxiety and worry (apprehensive expectancy) about a number of events or activities, occurring more days than not for at least 6 months (such as work or school performance), the individual has difficulty controlling his or her anxiety, and three (or more) of the following six symptoms are linked to anxiety and worry: Being easily fatigued, having difficulty concentrating, or having your mind go blank are all indicators of restlessness or agitation. Irritability manifests itself in the form of irritability, muscle tension, and sleep difficulties (American Psychiatric Association, 2013).
Dysthymic Disorder: Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years. Presence while depressed of two or more of the following: Poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decision, feelings of hopelessness. The disturbance is not caused by a substance's direct physiological effects (e.g., a drug of abuse or a medicine) or a general medical condition. Clinically substantial distress or impairment in crucial areas of functioning are caused by the symptoms. Although dysthymia was once thought to be less severe than major depression, its implications are now widely acknowledged to be serious, including significant functional impairment, increased morbidity from physical disease, and an increased risk of suicide. To determine a diagnosis of Dysthymic Disorder, the DSM-5 provides the following criteria. During the 2 years period, the person must have five or more symptoms, with at least one of them being either (1) sad mood or (2) lack of interest or pleasure. Changes in energy level, depressed mood most of the day, nearly every day, decrease or increase in appetite nearly every day, poor self-esteem, anxiety, isolation, appetite change, forgetfulness, not completing assigned chores at work or school, guilt, and loss of energy are all listed in the DSM-5 (American Psychiatric Association, 2013).
Reflection
Every mental intervention is determined by the information collected during the initial conversation with the client; every client's therapy starts with a comprehensive medical and behavioral health examination, the creation of trust, and a discussion of previous mental health history, substance abuse history, family mental health history, and so on. Individuals with whom they had connections that comprised effective communication, cultural awareness, and the absence of compulsion were considered as trustworthy (Sadock et al., 2014). One thing I might have done differently as a PMHNP is to meet the patient first, establish a therapeutic relationship, ask the young patient about his relationship with his parents, and then ask questions unrelated to the scheduled visit, which would help to create a welcoming atmosphere. Ask openended inquiries on the patient's personality, ailment, or personality without appearing to have a bias. Inquire about the patient's sexual orientation and preferred method of communication. Cultural competency includes elements such as trust, respect for diversity, respect for religion, equity, fairness, and social justice, which must all be considered during any interview or encounter between a healthcare practitioner and a patient (Sadock et al., 2014). When I interview a patient about their mental illness symptoms, I look at how they look, speak, and act to determine if there are any clues that could explain their symptoms.
The patient will begin individual supportive therapy then advance to family and peer group supportive therapy depending on level of improvement. The patient’s mother will receive an educational pamphlet, as well as assignments and a follow-up consultation, on themes that will aid in the healing and coping process. Patient will be started on fluoxetine (Prozac). An initial dose of 10 mg/day then increased to 20 mg/day after 1 week. Education and side effects of medication was provided for mother and son. Bedwetting can be avoided by limiting how much a child drinks in the evening, avoiding caffeinated meals and beverages, and promoting regular toilet usage throughout the day. Mother was told to wake the patient up at night to urinate and to make sure the patient's clothing were changed before going to school in the morning. Personal hygiene assistance should be provided to the patient. In case of emergency, the provider provided patient with helpful phone numbers: 911 for emergencies and the Client's Crisis Line. Reports from doctors and therapists were evaluated for mutual and collaborative understanding and for continuity of care. Patient’s mother was educated and was advised to call their primary care physician or go to the nearest emergency department if they had any questions or concerns about the development of any undesirable or unexpected outcome or side effects. Every 30 days, patient must return to psych tele-appointments for continuity of care and for provider to monitor progress and outcome of treatment but patient will return a week after starting Prozac for adjustment of dosing and to monitor improvement.
Essay (any type)
August 22, 2022
They have a magnificent team. These people are always kind and willing to listen to your concerns or issues. Better yet, your assignment is always ready before the time, they usually send you a draft to double-check before they finalize your paper.
Case study
August 22, 2022
Completed quickly and followed instructions given. Grammar, spelling, etc. was all good as well. Thank you so much! Will hire in the future.
Presentation/PPT
August 22, 2022
The work has not been graded but I like the output that was submitted to me. Is it possible for the same prof to do the next assignment I will be submitting? If possible, I will greatly appreciate it.
Journal article
August 22, 2022
My third using this writer and absolutely amazing work! Very punctual and very understanding.
Article
August 22, 2022
Outstanding job in writing my paper. I am always thrill to receive a well written paper that follows the instructions and the thorough details put into my paper. The quality of this paper is beyond awesome. Thank you so much.
Thesis/Thesis chapter
August 22, 2022
I absolutely love this writer! He/she always cranks out a fabulous paper and follows the assignment guidelines/instructions perfectly. Thanks again for always providing such quality work!!!
Research paper
August 22, 2022
It took some time to achieve the product I was looking for, but we eventually got there. I do feel like a lot of hard work was put into this, and it even exceeded the page requirement. I'm pretty pleased overall. I give my thanks.
Lab Report
August 22, 2022
Outstanding work! This writer followed every instruction and my paper came back with an A! I recommend to anyone needing help! Thank you again ❤️
Outline
August 22, 2022
Outstanding job in writing my paper. I am always thrill to receive a well written paper that follows the instructions and the thorough details put into my paper. The quality of this paper is beyond awesome. Thank you so much.
Essay (any type)
August 22, 2022
Made 100% on both the outline and the paper. Quick turnaround time and my writer responded within 30 min or less. Any edits my instructor needed, my writer was patient and worked diligently to accomplish the task. Would recommend my writer to anyone!
Essay (any type)
August 5, 2021
You are making my life so much easier! I am a single mom that works and goes to school. You guys are helping me with my projects so I can have more free time with my son.
Annotated Bibliography
August 5, 2021
I was sure it can fit in a single page but the next time I will add one more page because I am impressed with your professionalism and quality. Will use many more times till I graduate.
Essay (any type)
August 5, 2021
Simple registration and quality services. I just ordered one paper, and it was good enough to pass the exam. That is what I need the most. Good job.
Research Proposal
August 5, 2021
I couldn’t finish my freaking essay, and I was very desperate. A friend of mine sent me a link, and that is how I found out about you guys. Thank you for professional tips and editing. Now, I understand how to write it properly.
Reflection
August 5, 2021
I’m so grateful to you since you managed to complete my term paper in one day! You are definitely the best company ever!
Essay (any type)
August 5, 2021
I am sure on your ability to provide any type of paper I will order. I wish I could develop that skill your writers have to be able to have a flow of ideas and excellent sequencing of thoughts in writing.
Coursework
August 5, 2021
I ordered a thesis paper and was satisfied. All the guys were polite and highly professional, even when I wrote to them several times per day. Thanks for your passion!
Discussion Essay
August 5, 2021
I turned to the service twice, and my papers always were beyond the expectations. To tell the truth, I was ready to find some grammar errors or something like that. However, everything was neat and tidy.
August 5, 2021
My friend recommended Doctor My Essay to me. It is convenient! Now we both turn to the service periodically coz wanna save some time and use it more effectively. I know that while I’m developing my startup, an expert is working on paper. Time management in work!
Research Paper
August 5, 2021
I write all paper works by myself but have some problems with literacy. Actually, I have enormous problems because English is not my native language. However, with proofreading from Doctor My Essay, I can relax and don’t be ashamed of mistakes.
Argumentative Essay
August 5, 2021
Your ability to write concisely is a finding. The paper has a solid argument. It’s clear that the writer understood central claim about the topic. He also presented original ideas to consider.
Coursework
August 5, 2021
That paper got the highest grade in my class and the professor thinks I’m the smartest student. Lol.
Essay (any type)
August 5, 2021
I was convinced that paper writing services are the fiction for naive students. But when it came to my research paper that was to be composed in 72 hours, I had no other options. I made the right choice when I ordered it from you!
Business Plan
August 5, 2021
I was also satisfied with the service. Usually, I write everything by myself, but this time ( I have no idea how it happens!) I missed the deadline. My writer was very responsible, wrote the essay quickly, and kept the instructions. Nice to know that such experts exist!
Annotated Bibliography
August 5, 2021
It is really affordable! The prices start from 9$, which is an excellent proposal on the market. Recently I worked with another service that took much more money and provided lower quality papers.
Research proposal
August 5, 2021
I am absolutely satisfied. I am first timer here. Revision was made quickly, and the author met my expectations. Thanks a lot. Paper is phenomenal.
Essay (any type)
August 5, 2021
Having heard a lot of negative reviews about such services, I was a bit skeptical. However, our cooperation with Doctor My Essay was without pitfalls. I made two comments about the final work, and they re-wrote some parts very promptly. I am satisfied and will turn to them in the future.
Research paper
August 5, 2021
It was my first experience in online ordering, and I was a bit nervous. However, this was for nothing. I’ve got a high mark!
Dissertation
August 5, 2021
I understand that buying essays is a doubtful thing. You don’t put effort, don’t represent your ideas… However, I don’t perceive Doctor My Essay as a standard service. They don’t sell papers. They share high expertise!
Coursework
August 5, 2021
According to my previous experience, this service is really the best. They support the client and have competitive writers. I give them a perfect score!
Admission Essay
August 5, 2021
Nice service! It is cool that you can use the calculator on the main page and understand the price policy. For me, it is a huge plus!
Discussion Essay
August 5, 2021
Thanks to God I found this service! If I didn’t send my research to the teacher on time, he would eat me. I tell you! However, with doctor my essay service, I met the deadline, and I am still alive.
Report
August 5, 2021
Your service is excellent! Convenient and not expensive. Thanks for that!
Essay (any type)
August 5, 2021
If you have problems with time management, just like me, you need to cooperate with Doctor My Essay. Once you registered and made the order, you understand how easier it makes your life! Everything is online: ordering, communication… You can control the process everywhere and be sure that an expert will provide a high-level paper.
Calculate the price of your order
The price is based on these factors:
Academic level
Number of pages
Urgency
Basic features
Free title page and bibliography
Unlimited revisions
Plagiarism-free guarantee
Money-back guarantee
24/7 support
On-demand options
Writer’s samples
Part-by-part delivery
Overnight delivery
Copies of used sources
Expert Proofreading
Paper format
275 words per page
12 pt Arial/Times New Roman
Double line spacing
Any citation style (APA, MLA, Chicago/Turabian, Harvard)
Our guarantees
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
Money-back guarantee
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.
Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.
Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.
By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.
