FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

PATIENTS INFORMATION

S:15y/o female presents with chief complaint of increase excessive worry and lack of concentration for Psychiatry initial evaluation. Patient dealing with daily symptoms and requesting medical management to aid with symptoms.

Hx of mental health: Depression

Prescription Hx: Sertraline (Zoloft)

Symptoms: Irritability, difficulty falling and staying asleep, lack of concentration, restlessness or feeling on edge,

Triggers/stressors: unclear

Mood/Affect: Anxious

Suicidality: None reported

Substance Use: None reported

O: Insight and Judgement: No evidence of being outside normal limits

Thought Process: No evidence of being outside normal limits

A: Generalized anxiety, severe

P: Will prescribe medication to aid with anxiety symptoms. Prescribed Escitalopram 10mg PO daily. Selection based on patient’s presenting symptoms. F/U 1 month, or sooner if needed.

Patient was brought in for evaluation of worsening symptom, diagnosed with depression and anxiety at the age of 12 after the death of her father from car accident. She is in 10th grade, and experiencing increase worry that is affecting her academic performance and her participation in school game. Initially was as on Sertraline (Zolof) (dose unknown) and CBT, stopped Zoloft due to unpleasant side effect. Both parents had hx. of depression and anxiety, Pt have one sibling (elder brother 18 yrs). Pt is a member of basketball team in her school.

THE ASSIGNMENT

· 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 patient 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.

LEARNING RESOURCES

Required Readings

· Carlat, D. J. (2017).  The psychiatric interview (4th ed.). Wolters Kluwer.

· Chapter 28, “Assessing Neurocognitive Disorders (Dementia and Delirium)”

· MeditrekLinks to an external site. https://edu.meditrek.com/Default.html Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.

· Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016).  Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

· Chapter 10, “Stimulants and Other Meds for ADHD”

· Chapter 13, “Natural Medications in Psychiatry” (pp. 147–148 only)

· Chapter 14, “Dementia”