Focused SOAP Note and Patient Case Presentation

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QUESTION
Week 9: Focused SOAP Note and Patient Case Presentation
For this Assignment, you will document information about a patient that you examined during the last 3 weeks (SEE CASE SCENARIO BELOW), using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course.
To Prepare
• Select a child or adolescent patient that you examined during the last 3 weeks who presented with a disorder
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
The Assignment
• A full complex case will include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; Review of system (head to toe), most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
• 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 their 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: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
• 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.
Case Scenario
Patient is a 39-year-old AA female who is alert and oriented to person, place, time and situation.
Patient presented for follow up treatment of post-traumatic stress disorder and Substance-Related and Addictive Disorders. This was her first follow up with this provider since after being discharged from local mental health clinic. Patient has a history of childhood trauma from seeing her cousin being raped when patient was 5 and also from being molested by the same cousin as a child. Patient has intrusive memories and recurrent nightmares. She is chronically hypervigilant and easily startled. She withdraws from other people and especially avoids groups of men. She has had recurrent panic attacks and chronic problems with irritability and poor concentration. She became homeless earlier in 2020 after her aunt she was living with lost her family home. Patient was last treated with sertraline 150mg every day, but she stopped taking the medication over two months ago. She stated the medication made her feel “high”. She has had further stress over the past few months. Her sponsor of 15 years passed away. She received a DUI on 5 November 2021 that she attributes to current stressful problems. On the same day, she stated she was told she had a positive test for PCP and was followed by the court for this, but she denied she used it. Today her affect was depressed, anxious, and irritable. No suicidal ideation. She has chronic difficulty falling asleep and her sleep is interrupted. She has been having disturbing dreams. No significant problems with concentration and short-term memory. Weight has been increasing due to increase in calories intake.
Objective:
Weight (pounds): 236, Height: 5′ 7.5″ ,BMI: 24.98, Blood Pressure (Sitting): 160 / 82, Resp: 22, Pulse (Sitting): 80 BPM
Psychiatric History: History of counseling with Waldorf Behavioral Health, in 2007 and 2008. Hospitalized at Prince George’s hospital in 2016 for suicidal ideation.
Medical History: Fibroids causing hypermenorrhea; S/P partial hysterectomy on 6 November 2020. Anemia. Ovarian cyst. Fracture of left ankle in March 2020 s/p surgical fixation.
Legal History: History of incarcerations for drugs and assaults in 2003, 2007, and about 2012.
NKDA

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