SOAP

Chief complaint? (A) Violent behavior in response to undesirable tasks and noncompliance. This has resulted in being kicked out of two summer camps and we are experiencing violent resistance to attending the current special needs summer camp. The physical response to stress is so great that coping skills have been unaffective

Summary of visit:

Individual T.G seen in clinic face to face for psychiatric evaluation. She is accompanied by father and stepmother. Individual is alert and oriented x 3. Father states- "Two months ago I received a phone call from her mother stating that I needed to come get her because of behavior issues. They were in Maine. I brought her to Ga. I found out she was in SPED classed in Maine. She did fine in school here. She had some behavioral issues. This summer, she has gotten kicked out of two summer camps. We have had to call the mobile intervention team several times." Stepmother states- "When she gets angry, she throws things. Yesterday, she threw a glass at me and it shattered. When you say no or ask her to do something she does not like, her anger escalates. It is better if you distract her. She bites and fights as well." Individual has a mental health history of PTSD, anxiety, ADHD and conduct disorder. Denies SI/HI. Individual asks to step out of room after about ten minutes in session.

Family History- Mother (living)- bipolar disorder, schizophrenia, substance use disorder

Father (living), no mental health or medical history

HX: childhood trauma- Father reports that individual witnessed domestic violence, there is also a question of abuse at age 3 by 7 year old female family member

Surgical Hx- no surgical history

Reproductive History- Cycle at age 11

ROS- (+) anxiety/depression, (-)hallucinations/delusions, (-) sleep

Diagnoses attached to encounter

DIAGNOSES ATTACHED TO THIS ENCOUNTER

Conduct disorder [ICD-10: F91.9], [ICD-9: 312.89], [SNOMED: 430909002]

Generalized anxiety disorder [ICD-10: F41.1], [ICD-9: 300.02], [SNOMED: 21897009]

Post-traumatic stress disorder, chronic [ICD-10: F43.12], [ICD-9: 309.81], [SNOMED: 313182004]

Attention deficit hyperactivity disorder combined [ICD-10: F90.2], [ICD-9: 314.01], [SNOMED: 31177006]

Disruptive mood dysregulation disorder [ICD-10: F34.81], [ICD-9: 296.99], [SNOMED: 715924009]

Medications/Prescription orders attached to encounter

MEDICATIONS ATTACHED TO THIS ENCOUNTER

FLUoxetine HCl 10 MG Oral Capsule Take one tab daily

ARIPiprazole 5 MG Oral Tablet Take one tab nightly

FLUoxetine HCl 20 MG Oral Capsule Take one tab daily

Care plan

Start aripiprazole 5 mg daily. Start fluoxetine taper- Start fluoxetine 30 mg x 1 week, after start fluoxetine 20 mg x 7 days, afterwards start fluoxetine 10 mg x 7 days. Monitor for and report side effects to NP. Call 988/911 in case of mental health/medical emergency. Follow up in 4 weeks.