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Original Question

Case Study Because a patient, 36-year-old Hispanic-American male, Kevin, has been showing signs of addiction to Xanax, the primary care provider decides to discontinue the patient’s Xanax prescription and refer for psychotherapy. The patient responds with anger, pleading that he can’t function without the medication. As you move through the initial assessment, the patient states that he had a back injury on the job. He works for a concrete company and fell into a prepped basement area before the concrete was poured. He had some pain meds during recovery and was given Xanax for increased anxiety. He states he enjoys his job very much and that he cannot lose it as he is the sole provider for his family. He lives with his wife and twin boys, age eight. He stresses again that he works hard for his family and can’t afford to miss work due to anxiety so he needs the Xanax to function. He denies any substance abuse or past medical history other than the back injury eight months prior. He has no legal history and no military history. His extended family lives near, and he reports a pleasant childhood with continued support even still. Vitals: BP= 138/90, HR =76, R 20, T= 97.2, O2= 99%, Pain 5 on 0-10 scale (back pain) Follow-up Session SOAP Note Accompanied by: CC- (Chief Complaint): HPI- (History of Present illness): S- (Subjective): Crisis Issues: Reviewed Allergies: Current Medications: ROS: O-(Objective): Vitals: PE: (not always required and performed, especially in psychotherapy only visits) Heart- Lungs- Skin- Labs: Results of any Psychiatric Clinical Tests: MSE: A – (Assessment). with (ICD-10 code) Differential Diagnoses: 1. choose 3 differential diagnoses (give rationale for diagnoses to support DSM5 criteria) 2. 3. Definitive Diagnosis: P- (Plan): Pharm: Non/Pharm: Continue outpatient counseling: Psychotherapy Modality used: CBT Interventions/Homework: Educations: Safety Plan: Follow-up:

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