I will attach the template that needs to be completed for this assignment. If there is no information provided, it is okay to “make up” or “fabricate” information to make the SOAP note complete.
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
- Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
- Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
- In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
- Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
- 11 year old patient:
Reason for Appointment 1. 1 month follow up
History of Present Illness HPI: This is an 11 yo Caucasian female accompanied by her father seen with symptoms of Anxiety, Depression and ADHD for follow-up evaluation. She is taking 2 of the Hydroxyzine at bedtime and sometimes a 3rd during the day. Her anxiety has been higher recently and she is not sure why. School and the home routine have not substantially changed. Patient started singing lessons. Patient is 11 years old but does act much younger during assessment.
ADHD – She is responding to the Qelbree and tolerating better than the previous Focalin. She has a high level of anxiety and did not tolerate the stimulant. She has been better able to complete tasks and maintain her attention on school and home activities. She is going to school and is getting good feedback. She is getting extra help with reading and this does increase her anxiety when she has to read a lot if she struggles. Presence of symptoms of Mood – sadness at times and tends to be an emotional person, tearful easily, denies mania.
Presence of symptoms of Anxiety – worry and separation anxiety. She is uncomfortable going to bed alone and anxiety spikes in the evening leading up to bedtime. Night time is harder the days her father works night – Wed to Saturday. Hoping to change the anxiety cycle and her reaction. Some baby talking today and biting her fingers, reports anxiety tends to be highest in the afternoon and evening.Some fixation and compulsions to seek reassurance and comforting when there is something she is looking forward to or they have plans in the future. She will call her mother at work numerous times when anxiety is high.Absence of psychosis – hallucinations, delusion or disorganized thoughts.Presence of problems with sleep – bedtime is challenging as she does not sleep alone and so is still in parent’s bed. If they stay up after her bedtime she frequently is unable to calm herself and go to sleep. The hydroxyzine helps her to settle better. Absence of problems with eating – appetite, binge eating, anorexia, weight changes.
Absence of suicidal ideation
Absence of homicidal ideation.
Vital Signs
Examination
Mental Status Exam:
APPEARANCE: casually groomed, appears actual age.
COGNITION: alert and oriented to person, place, date and situation.
SPEECH: normal rate, soft volume, short one word answers
EYE CONTACT: appropriate.
MOOD: anxiety.
AFFECT: congruent.
THOUGHT PROCESS: logical, goal directed.
THOUGHT CONTENT: appropriate thought content.
PSYCHOMOTOR: normal. Psychosis: no evidence, patient denies.
PERCEPTION: no evidence of internal preoccupation, paranoia.
CONCENTRATION: focused and able to engage.
JUDGEMENT/INSIGHT: intact.
Assessments
1. Attention-deficit hyperactivity disorder, combined type – F90.2 (Primary)
2. Anxiety – F41.9
Treatment
1. Attention-deficit hyperactivity disorder, combined type
Refill Qelbree Capsule Extended Release 24 Hour, 200 MG, 2 capsule, Oral, Once a day
Start Escitalopram Oxalate Tablet, 5 MG, 1 tablet, Orally, Once a day, 90 days, 90 Tablet
2. Anxiety
Start hydrOXYzine HCl Tablet, 10 MG, 1 tablet as needed, Orally, Three times a day,
3. Others Notes: Adding Lexapro for anxiety and to support her moods
Continue Qelbree
Continue Hydroxyzine
Provided supportive psychotherapy for 16 – 36 minutes using a motivational interviewing mindfulness to support patient autonomy, utilizing coping skills and healthy lifestyle habits
Encouraging minimum 15 minutes of physical activity daily.
Encouraging turning off technology 1 hour before desired bedtime.
Encouraging 7+ hours of sleep nightly.
Encouraging meaningful activities and social contacts daily.
