Assignment 2: Focused SOAP Note and Patient Case Presentation

CASE STUDY

Subjective

Patient is 24-year-old AA female seen today via Telehealth with consent obtained. She reports that she has been going through stuffs and need specialist to address her mood issues. She continued that this mood issue days' back to 2019 and she was put on Seroquel. However, she admits that because she was pregnant then, she did not go back to continue to get help. After birth according to her, she navigated through life barely until now. Presently, I have been going through stressful things and am beginning to get aggressive with people. I noticed that am verbally and physically abusive to people for little stuff or triggers." I need help". She gave a background history that she experienced traumatic life with stepfather children abuse sexually at age of 10. Growing up with no parents in my life affected me also. I had couple of medical and mental health hospitalization. In one of the admissions in psychiatric hospital, I was given Seroquel and I feel like i need to get back to that as it helps me with my mood and sleep. Currently, I hardly get 4 hours of sleep and sometimes I do not get any.

Assessment Patient report that her mood issue dates to 2019 and she was put on Seroquel. However, she admits that because she was pregnant then, she did not go back to continue to get help. After birth according to her, she navigated through life barely until now. Presently, I have been going through stressful things and am beginning to get aggressive with people. I noticed that am verbally and physically abusive to people for little stuff or triggers." I need help". She gave a background history that she experienced traumatic life with stepfather children abuse sexually at age of 10. Growing up with no parents in my life affected me also. I had couple of medical and mental health hospitalization. In one of the admissions in psychiatric hospital, I was given Seroquel and I feel like i need to get back to that as it helps me with my mood and sleep. Currently, I hardly have up to 4 hours of sleep and sometimes I do not get any. The provider reviewed her chart and condition and believe she will benefit from Therapy and will resume Seroquel 50mg at bedtime. Educated her about her disease’s progression and medication side effects.

PHQ 9 score-18/27

Diagnoses (F31.9) Bipolar disorder, unspecified

Plan

Plan in 90 days is to decrease mood disorder

To call 911 feeling suicidal or homicidal

Take prescribed Seroquel 50mg

Educated her on medication side effects or interactions

Patient is refer to Psychotherapy

To follow up in 4 weeks.

MEDICATIONS

Quetiapine Fumarate (SEROquel) 50 MG 1 tablet by mouth daily at bedtime