WK3 ASSIGN2 PRAC 6675
Ifeoma12
CLINICALPRAC6675.docxRUNNING HEAD: STUDY PLAN 1
STUDY PLAN 9
Cole Neal
17 yrs M
Invite to Patient Portal
DOB:
09/16/2004
M:
New Encounter
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SOAP Note
DATE
06/07/2022
AGE AT ENCOUNTER
17 yrs
SEEN BY
FACILITY
Chief complaint
My depression is getting better
Note
Subjective
Met patient individually and then with Sherri, his mother. Mom reports he is doing "good" relationship with his parents is well. He passed all his classes his GPA was better. He wants to decrease the dose off the Zoloft. We discussed with Sherri and she agrees. Denying any panic attack or anxiety. Sherry is also reporting that he is not taking the medication regularly. He has been stable for the last 6 months. sleep is restful. appetite is picking up. mood is stable. denies suicidal ideation or homicidal ideations. denies hallucinations or delusions. denies alcohol abuse. denies drug abuse. Is getting a job for summer and he also has planned a couple vacations. review of systems: patient denies fatigue, fever,dry mouth, vision change, hearing change ,heart palpitations, shortness of breath, nausea, stool changes, dysuria, dizziness, weakness or rash. Patient denies any muscle pain/joint Pain.Denies diabetes/ Thyroid issues
Past, family, social history (PFSH) no change.
Objective
mental status exam: appearance is normal. hygiene and grooming is fair. calm and cooperative. alert and oriented times 4. psychomotor is normal. speech is clear and coherent. thought process is logical and sequential. gait is normal. language is normal. mood is stable. affect is congruent with mood. denies hallucinations or delusions. denies suicidal ideations. denies homicidal ideations. associations intact. recent and remote memory intact. concentration is fair. intelligence is normal. judgment is fair. insight is fair.
Assessment
Problems/condition: Established patient Medical decision-making: straightforward . low . mod X. high Problem/condition: problem/condition new established X. status: improving worsening stable X Comorbidities: X stable complications/side effects independent management required interferes with management of primary condition.
Diagnoses attached to this encounter:
· Major depressive disorder, single episode, moderate [ICD-10: F32.1], [ICD-9: 296.22], [SNOMED: 15639000]
Plan
Print visit summary
Treatment plan:
Decrease Zoloft 50 mg by mouth daily.
Mom to watch him closely and if patient feels more depressed to talk to mom schedule a therapy appointment and call our office for an earlier appointment intervention/psychotherapy: continue to work on enhancing coping skills and implementing them. Continue CBT. Medication: as follows
Spent 15 -20 minutes face-to-face with patient , Educating, counseling and reviewing treatment plan.
return to clinic in 4 weeks.
|
MEDICATIONS ATTACHED TO THIS ENCOUNTER |
|
Zoloft 25 MG Oral Tablet Take 2 tablets (50 mg) by mouth daily (start date: 6/7/2022) |
