You do not need to do the title page…I will take care of that.
I need all information filled out on attached SOAP note template. It is OKAY to use some fictional information to complete this patient’s SOAP note and make it complete but please keep all listed information relevant in this assignment. I will also attach an example of what is needed and required to be included on the template. Treatment plan and Differential Diagnosis are both very important to include with resources…please follow the exemplar!
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. 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 again? 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.
ASSESSMENT:
Reason for Appointment 1. Establish care, from missouri has ADHD
2. RH – ADHD Rating Scale
History of Present Illness
HPI: This is a 19 yo Caucasian female seen with symptoms of ADHD and Anxiety for initial psychiatric evaluation.
Presence of symptoms of Mood – sadness her senior year when her father went to alcohol rehab, denies mania. She notices that the zoloft is muting her emotions and decreased sexual interest.
Presence of symptoms of Anxiety – social anxiety, has fainted when anxiety is high, would rather miss something than walk in late and have people look at her. Uncomfortable around drunk people as this brings up her father’s alcohol behaviors.ADHD – She is taking Adderall XR 10 mg and feels it has a positive but faint effect.
Absence of psychosis – hallucinations, delusion or disorganized thoughts.
of problems with sleep – difficulty falling asleep and wakes early, no bad dreams
Absence of problems with eating – appetite, binge eating, anorexia, weight changes.
Absence of suicidal ideation.
Absence of homicidal ideation.
Substance Use history – Not an issue.
Screenings: ADHD Rating Scale Fails to give close attention to details or make carless in schoolwork/homework 2 – OftenHas difficulty keeping attention on tasks or play activities 3 – Always or very oftenDoes not seem to listen when spoken to directly 1 – SomewhatDoes not follow through on instructions and fails to finish schoolwork or chores. 3 – Always or very oftenHas difficulty organizing tasks and activities 3 – Always or very oftenAvoids or strongly dislikes tasks that require sustained mental effort (e.g., homework) 2 – OftenLoses things necessary for tasks or activities (e.g., pencils, books, toys, etc) 0 – Rarely or NeverIs easily distracted by outside stimuli 1 – SomewhatIs forgetful in daily activities 3 – Always or very oftenFidgets with hands or feet or squirms in seat 3 – Always or very oftenLeaves seat in situations in which remaining seated is expected (e.g., dinner table) 1 – SomewhatRuns about or climbs in situations where it is inappropriate 2 – OftenHas difficulty playing quietly 0 – Rarely or NeverIs “on the go” or acts “driven by a motor.” 1 – SomewhatTalks excessively 2 – OftenBlurts out answers to questions before the questions have been completed 0 – Rarely or NeverHas difficulty awaiting turn 1 – SomewhatInterrupts others or intrudes on others (e.g., butts into games) 3 – Always or very oftenVital SignsExamination
Mental Status Exam:
APPEARANCE: casually groomed, appears actual age.
COGNITION: alert and oriented to person, place, date and situation.
SPEECH: normal rate, normal volume.
EYE CONTACT: appropriate.
MOOD: euthymic.
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. Assessments1. ADHD (attention deficit hyperactivity disorder), combined type – F90.2 (Primary) 2. Social phobia – F40.10 Treatment1. Others Refill Zoloft Tablet, 25 MG, 1 tablet, Orally, Once a day, 14 days, 14 Tablet, Notes to Pharmacist: Tapering 50 mg for 2 weeks, 25 mg for 2 weeks then stop Refill Zoloft Tablet, 50 MG, 1 tablet, Orally, Once a day, 14 days, 14 Tablet, Refills 0, Notes to Pharmacist: Tapering 50 mg for 2 weeks then 25 mg for 2 weeks then stop Start Adderall Tablet, 10 MG, 1 tablet, Orally, once a day As needed, 30 days, 30 Tablet, Refills 0 Refill Adderall XR Capsule Extended Release 24 Hour, 10 MG, 1 capsule in the morning, Orally, Once a day, 30 days, 30 Capsule, Refills 0 Start Vilazodone HCl Tablet, 10 MG, 1 tablet with food, Orally, Once a day, 14 days, 14 Tablet, Notes to Pharmacist: Starting 10 mg for 2 weeks then 20 mg Start Vilazodone HCl Tablet, 20 MG, 1 tablet with food, Orally, Once a day, 30 days, 30, Refills 1 Notes: Continue Adderall XR and adding an IR dose PRNSwitch from Zoloft to Viibryd to help with side effects – obtained informed consent
Discussed benefits of counselingApplied principles of motivational interviewing
Aware of suicide hotline – 988
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.
Current Medications
TakingAdderall XR 10 MG Capsule Extended Release 24 Hour 1 capsule in the morning Orally Once a day
Zoloft 25 MG Tablet 1 tablet Orally Once a day
Zoloft 50 MG Tablet 1 tablet Orally Once a day
Not-TakingStrattera 40 MG Capsule 1 capsule in the morning Orally Once a dayMedication List reviewed and reconciled with the patient
Past Medical HistoryMedical History Verified.
Surgical HistoryDenies Past Surgical History
Family HistoryFather: AlcoholMother: Depression2 brother(s) .
Social History
Drug/Alcohol: Drugs Have you used drugs other than those for medical reasons in the past 12 months? No
Do you smoke marijuana?: Denies.
Do you drink alcohol?: No.
Miscellaneous: Origin: Moved from Missouri for school at ASU.
Education Highest level of education College At ASU studying child development
Living Situation: Living in a house with 3 roommates.
Employment: Working at Sephora.Enjoyable Activities: She is in a dance club team.
Psychiatric History: Initial Treatment: She has been taking
Zoloft for about 2 years and started Adderall last year..
Past Hospitalizations: ER for panic attack in 2022.
Self Harm: None.
AllergiesN.K.D.A.Hospitalization/Major Diagnostic
ProcedureDenies Past Hospitalization
Review of SystemsROS negative.