Assignment 2: Focused SOAP Note and Patient Case Presentation

Patient is 44-year-old African American female seen in the clinic with consent for chief complaint of "PTSD" or depression. She reports her little brother died in 2019 and her mother died in 2020. She says she briefly sought a mental health therapist in the past but was unable to connect with the therapists. She reports her family of mental illness is not confirmed but she believes her mother had depression and OCD. She was raised primarily by her mother. She reports a good relationship with her biological father who has been very active in her life. She says her 30-year-old-daughter has ADHD. She reports she was sexually abused by her stepfather from the ages of 6-12 years old and her mother physically abused her. She became pregnant at 14 and was able to earn her GED. Patient reported very poor appetite. She is sleeping only four hours per night and sometimes not at all. She reports she cannot think or focus on her job and is fearful of losing her job. She reports I feel so bad "I don't even want to put clothes on". She says she is not actively suicidal but she "Thinks about how it would be if I weren't here. I don't have a plan or anything". She smokes marijuana "All the time" and is increasing her alcohol intake. Provider prescribed escitalopram 5mg every morning for her depression and will increase when appropriate. Hydroxyzine 25 mg three times a day as needed for her anxiety. Patient was educated on abstaining from smoking marijuana and consuming alcohol. Instruct patient in the use and side effects of escitalopram and hydroxyzine. Patient to call 911 for thoughts of suicide and homicide ideation.

PHQ score 21/27.

Diagnosis of Severe Depression

Vital Sign: T-98.6, R-20, P-82, B/P-130/78, Oxygen sat 100% R/A, Wt-170lbs

Plan: in 90 days patient will have decreased symptoms of depression.

Provider educated patient to abstain from smoking marijuana and consumption of alcohol while taking Escitalopram and hydroxyzine as they will affect effectiveness of the medications. Patient verbalized understanding.

Provider educated patient in the use and side effects of escitalopram and hydroxyzine. Instructed patient that feelings of abdominal pain, nausea and heavy headedness will pass and to continue taking medication

Provider will instruct patient to call 911 for thoughts of suicide and homicide ideation.

Follow-up visit in 2 weeks.