FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

Chief complaint: “My daughter is not eating well, and she is gradually losing weight.” HPI: Patient is a 16-year-old Caucasian female who reports to the office with her mother with complaints of poor eating, purge eating, and weight loss of approximately 10 lbs in the last month. Patient mother states she has recently noted that her daughter has a preoccupation with weight loss, exercise, pictures of slim-fit models, and movie stars, which she hangs on her bedroom walls, closet, and bathroom. Patient states she will eat and induce vomiting after she feels she is “too full after a large meal.” Pt states she feels a “loss of control.” and deeply feels remorseful when she eats more than she would like. Mother reports she has few friends and tends to isolate herself and started doing that after pt. lost her dad at age 14. Mental Status Examination: Patient is AOX3. She is well-groomed and dressed appropriately for the weather. Pt. gets easily distracted with poor eye contact but does not disrupt the communication. Speech is clear, coherent, and normal content. She is guarded, mood is sad/depressed. Appropriate cognition and thought process. Struggles to stay focus. Diagnosis: F50.2 Bulimia nervosa F33.1 Major depressive disorder, recurrent, moderate Treatment plan Pharmacological: Started on Fluoxetine 20mg PO once daily to be titrated as tolerated. Non-Pharmacological: Labs CMP, TSH free T4, and EKG ordered. Practitioner discussed with the patient and mother on starting psychotherapy. A nutritional consult was also ordered. F/U scheduled in 2 weeks.

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Chief complaint: “I am doing well, except my anxiety is getting worse” HPI: Pt S. S. is an 11-year-old African American female who presents today to a follow up with his father. Father complained pt is suffering from anxiety. Pt lost her mother last year due to covid. The patient has a history of ADHD. Father reports pt sleep has improved as well as her attention span. Pt c/o school lockdown that she is not able to play with her best friend. Mental Status Examination: Pt is alert and oriented to person, place, and time. Well-groomed for the weather and well-nourished. She appears anxious. Euthymic affect, speech is rushed but clear and appropriate for age. Patient denies suicidal and homicidal thoughts, no auditory or visual hallucination. Attention span is stable. Diagnosis: F41.1 Generalized Anxiety Disorder. F90. 0 ADHD, predominantly inattentive type Treatment plan Pharmacological: Continue Adderall 5 mg PO twice daily Hydroxyzine 12.5 mg PO PRN at bedtime Zoloft 25 mg PO daily Non-Pharmacological: Patient and father were encouraged to continue with CBT group therapy once a month. Risk and benefits of medication and the client and father verbalize understanding. Follow up scheduled in 2 weeks.

• 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 patient 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: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
• In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
• 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.

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Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

Family Therapy: the family members involved in today’s therapy session are S.O (Mother), K.C(Father), and T.A (son).  T.A is a 12 years old Caucasian boy who apparently became moody and refuses to talk to both of his parents because his parents are getting a divorce. Other symptoms parents noticed from T.A are Mood swings, Fear, Social withdrawal, Flat affect, neglected appearance, Feeling of anger, and lost interest in favorite activities. Father and mother argue every day in front of T.A. T.A was an A student in his class but now perform poorly in all his classes. Parents express concern that they think their son is depressed and they will like him to express his feeling about their divorce. Looking into his chat, T.A does not have any medical or psychiatric conditions. He takes only one a day multivitamin. The therapist diagnosed T.A of severe depression. The treatment plan for T.A is to establish coping skills for his parent separation, to be able to express his feelings with his family, to do at least two interesting activities of his choice every day. The therapist scheduled T.A to come for every week’s session until positive changes are seen.

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