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Discuss Subjective data: • Chief complaint • History of present illness (HPI) • Medications • Psychotherapy or previous psychiatric diagnosis • Pertinent histories and/or ROS Discuss Objective data: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses Discuss results of Assessment: • Results of the mental status examination • Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms. Discuss treatment Plan: • A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected. Reflect on this case. Discuss what you learned and what you might do differently. Focused SOAP Note documentation Presentation style ——————————————————————————————————————————————— Subjective: CC (chief complaint): “I am feeling overwhelmed.” HPI: AC is a 16-year-old white female who presents for evaluation of suicidal ideations. Pt was accompanied by her mother. Patient interviewed alone; Reports school is stressed. Notes a hard time with a focus both directly and with directions. States she is forgetful with assignments at times also. Her parents, she feels expect her to be perfect like her sister which is not something that is possible. Notes they do not understand that struggles of poor focus and so the goals they set such as no work assignments are not possible. States she often fights with father as he expects perfection above himself but is a narcissist and so it’s not possible. Also discusses bullying in past during various grades. States it was difficult to have a person at home physically abusing you and telling you to die and telling you to die and then going to school and being told to die by peers. She states she has come to a point of just not caring and that has been working for her. Notes if other are not part of her life and thriving then she isn’t needed for them. Multiple times in interview she discusses not caring and how she isn’t needed by anybody and wanting one’s company is not reason enough. Endorses good sleep and energy level. Sates appetite is doing poor. States most of times has not appetite but at others thing she doesn’t eat to replace past SIB or cutting. She reports her anxiety is different in that she often thinks about ‘what if scenarios more constantly She does report being irritable with muscle tension when anxious. States she often more fatigued as well. Panic attack come various times per week. Triggered from loud noise/hearing being affected. Notes she is deaf and she cannot control her hearing so when something is affecting that it is more anxiety spiking for her. States she has big ideas for the future that are in her head for a screenplay, and she needs to get them done. She does feel the Zoloft has lessened these thoughts to not exist and perhaps increased motivation. Denies any thoughts to harm others alone with no hallucination. Denies manic episode. Denies substance use. With focus she reports difficulty sustaining focus and trouble with detailed attentions. States will drift off when spoken to and can’t stay organed. Is easily distracted in class. Often forgetful and losing things. Reports vary fidgety and can’t stay still in seat for long periods. Notes difficulty waiting turn is often very talkative and interrupting others when they speak to she can get her thoughts out before forgotten. MEDICATIONS: Current Medications: Zoloft 25 mg po once daily Focalin XR 10 mg po every morning Psychotherapy or previous psychiatric diagnosis: Past year and they are starting with new therapist as previous one was not a good fit. Current therapist: Greater vision, just started. Past Psychiatric History: At age of first eval at 15-year-old patient has been seeing therapy from PCP and was previously diagnosed with an ADHD (attention deficit hyperactivity disorder and Depression. At that time patient was requesting Zoloft due to “Wellbutrin not working.” Past psychiatric admissions: none, in hospital ED last month. Previous suicide attempts-attempted drowning 2 years ago by putting head underwater in bathtub. Her mother indicates she has had depression for over a year has been receiving Wellbutrin as an outpatient without improvement. Past history of self-injury behavior of cutting. Patient was verbally and physically abused by older cousin as a child. Same time older sister was sexually abused. Last year good friend committed suicide. Grandmother, cousin and aunt passed away in past year. Substance Current Use: Patient denies any current substance abuse use. Allergies: Latex cause rashes and Peanut swelling throat. Wellbutrin did not help. Reproductive Hx: Patient has no children and no relationship. Menses are regular once a month. Denies pregnancy. No reported risky sexual behavior. ROS: General Physical Issues Reported: No weight loss, fever, chills, weakness, or fatigue. Skin: No rash or itching. HEENT: no headache, no head injury, no dizziness, no light headaches, no vison changes. Congenital hearing loss, wears hearing aids. No tinnitus, no vertigo, no earaches, no nasal stuffiness, no nasal discharge, no nosebleeds, no sinus trouble, no dry mouth, no hoarseness. Neck: no lumps, no lymphadenopathy, no goiter, no pain no stiffness Cardiovascular: no chest pain or discomfort, no palpitations, no dyspnea, no orthopnea, no paroxysmal nocturnal dyspnea, no edema Reparatory: no cough, no sputum, no hemoptysis, no dyspnea, no wheezing Gastrointestinal: no trouble swallowing, no heartburn, no nausea, no vomiting, no diarrhea, no rectal bleeding or tarry stool, no constipation, no abdominal pain no food intolerance Genitourinary: no complaints of urinary urgency, frequency, or painful urination Neurological: no complaints of headaches, numbness, or ataxia Musculoskeletal: no complaints of muscle or joint pain Lymphatics: no complains of swollen or painful lymph nodes Endocrinologic: No heat or cold intolerance, no excessive sweating, no excessive thirst or hunger. No polyuria Objective Diagnostic results: Provider did not request any labs at this visit. Patient last labs were collected on 01/27/22 all labs’ results WNL. Patient had a CMP, CBC with diff, thyroid panel, lipid panel vit D and HBA1c was normal. urine drug screen negative. pregnant test negative, Has 504/IEP for hearing loss. Past medication Trial: Wellbutrin-did not help Surgical History: She has no past surgical history on file Family History: family history includes anxiety disorder in her maternal grandmother and mother; Depression in her mother Social History: She reports that she has never smoked. She has never used smokeless tobacco. She reports that she does not drink alcohol and does not use drugs. She is in 10 th grade. Assessment: Mental Status Examination: Patient is a 16 -year-old Caucasian appears stated age and female playing with pop it normal posture. Initially guarded but does open with time, intermittent eye contact. Speech is normal in rate, rhythm, volume. Thought processes is linear. Thought content is normal. Mood is overwhelmed. Affect is anxious; Denies hallucinations but endorses suicidal ideations denies suicidal plan and denies homicidal ideations. Level of consciousness: awake and alert. Cognition; oriented, good attention and good concentration. Knowledge is intelligence appears normal. Insight; partial Judgement; partial Reliability; patient reliable in interview information. Diagnostic Impression: Major depressive disorder, recurrent several (F 33.2): Endorses depressed or sad mood and endorses diminished interest or pleasure in activities and endorses fatigue or loss of energy and endorses feeling of gilt or worthlessness, and endorses impaired concentration and endorses suicidal ideations, and endorses that symptom cause clinical distress or impairment (Kanter et al., 2018). DSM-5 classifies a anxious distress has been noted a prominent feature of both bipolar and major depressive disorder ran both primary care and specialty mental health settings. High level of anxiety has been associated with higher suicide risk (APA ,2013). Longer duration of illness and greater likelihood for treatment nonresponse. As a result, it is clinically useful to specify accurately the presence add severity levels of anxious distress for treatment planning an monitoring of response to treatment. The following manic/hypomanic symptoms are present nearly every day during the majority of days of a major depressive episode (Ng et al., 2016). Generalized anxiety disorder (GAD) (F41.1): Client’s anxiety is variable and is mild in nature. Frequent, mild symptoms of nervousness, worrying, restlessness. Racing thoughts are apparent from time to time (Ansara & Schulte, 2017). Client reports excessive anxiety and worry more days than not, and endorses restlessness or feeling on edge, and endorses being easily fatigued, and endorses irritability and endorses muscle tension and endorses anxiety and worry causes distress. (Strohle et al., 2018). DSM-5 classified GAD is anxiety disorder that involves excessive worry, periods of restlessness and irritability for six months or more (APA, 2013). These symptoms are often distressful, leading to impaired school, social functioning. Attention deficit hyperactivity disorder, combined presentation (F 90.2): Evidence of falling to give close attention or making careless mistakes, and evidence of difficulty sustaining attention in tasks of play and evidence that one does not listen when spoken directly to and evidence one does not follow through on instructions (Risiyanti et al., 2021). There is evidence of failing to finish duties, and evidence one dislikes or avoids tasks requires sustained mental effort and evidence of often losing things necessary for tasks or activities and evidence one often fidgets or squires in seat and evidence one often leaves seat when remaining seated is expected, and evidence one is ” on the seated is expected, and evidence one is ” on the go” or acts as if” driven by a motor.” And evidence of talking excessively and evidence one blurts out answers before questions re completed, and evidence one has difficulty waiting for his or her turn, and evidence one often interrupts or intrudes or others. Evidence symptoms are present in 2 or more setting and clear evidence symptoms impact functioning. DSM-5 reports that combined presentation both inattention and criterion hyperactivity-impulsivity are met for the past 6 months (APA,2013). Reelections: reflection on this case one of the main things I have learned is to listen to the patient. This patient may have been suffering diagnosed as MDD, GAD and ADHD my preceptor was able to give her the proper medication and increase medications. The Wellbutrin is no long working, she states some time has no appetite but at other things she does not eat to replace past SIB of cutting. She reports her anxiety is different in that she often thing about what if scenarios more constantly. Notes worthless feeling are a constant. Has had some SIB urges but not cut since seen in hospital. I fully support the decision my preceptor made, with her diagnosis and changed the medications increase. Mental disorder effect the capability to decision when you are having for mood episode and remains a stigmatized condition, so the degree of patient’s independence in the medical care must be measure from an ethical perspective and I think my preceptor allowed the patient to take part in her mental health by listening to her about which medication she felt worked best for her. Case Formulation and Treatment Plan The client is evaluated for the following symptoms during today’s assessment depression, anxiety, sadness, panic, impulsivity, suicidal ideation. The client’s medication will increase Focalin XR to 15 mg QAM, and Zoloft 50 mg daily reconciled with any update to the therapeutic regiment and adjustment are reflect in the both the client chart and clinical note. Side effects responded by the client or that are assessed by the treating provider are documented in the chart with necessary adjustments or actions taken. Medical history is reviewed and updated per client report. Social history is reviewed and updated per client report. Medication educations/counseling provided was provide with following education and verbalized understanding. Medication dose and time to take, purpose expected benefit sand risks of medicine. Common side effects expected length of treatment, financial assistance/availability, alternatives to prescription medicine, risks of medication non-adherence or refusal of treatment. In addition to the current identified client goal, the following general treatment goals were discussed with patient symptom reduction, medication adherence, maintain therapeutic gains, restore level of functioning, reduce reliance on medication for symptom management. Patient agrees to return to clinic sooner/call provider if suicidal/homicidal ideation occurs or if audiovisual hallucinations present or worsen. Client is advised to adhere to treatment plan(s) to prevent relapse and regression of progress. Client is advised of emergency services, including crisis Physical handout on local crisis hotlines are made available to client for convenience. Client/Guardian can call office or seek emergency services for acute worsening of symptoms or risk of danger to self or others. Crisis hotline information is additionally located on the practice’s website. The client is encouraged to call these crisis lines if having after-hours suicidal or homicidal ideation as the client understands that the office will be unable to assist them with an emergency after hours. Client verbalized understanding of education about crisis line and consents to call if having after-hours issues. Labs / Referrals / Care Coordination: Referral has been made to outpatient counseling services. The evaluation and management / integrated psychotherapy (Yin et al., 2021). The practitioner and the client agree to work toward the following therapy goal(s): Enhance coping skills in an effort to help client cope with new situations and challenges, Promote behavioral change by enabling client to live a more productive and satisfying life‚ identifying specific and measurable goals to gauge client success, allow client to see how emotions‚ attitudes‚ and values influence decisions and choices, Promote positive decision making practices in an effort to assist the client make good decisions and realize the consequences of bad decisions. The client’s progress toward therapeutic goals is assessed during today’s appointment. The client is recommended to attend individual / group therapy in addition to pursing medication management services as the rendering provider believes that the client would benefit from additional therapeutic interventions and follow-up to realize proposed goals. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders(5th ed.). Washington, DC: Author. Kanter, J. W., Busch, A. M., Weeks, C. E., & Landes, S. J. (2018). The nature of clinical depression: symptoms, syndromes, and behavior analysis. The Behavior analyst, 31(1), 1-21. https://doi.org/10.1007/BF03392158 Ng, C. W., How, C. H., & Ng, Y. P. (2016). Major depression in primary care: making thediagnosis. Singapore medical journal, 57(11), 591-597.https://doi.org/10.11622/smedj.2016174 Ristiyanti, N., Dirgantoro, B., & Setianingsih, C. (2021). Behavioral Disorder Test to Identify Attention-Deficit / Hyperactivity Disorder (ADHD) in Children Using Fuzzy Algorithm. 2021 IEEE International Conference on Internet of Things and Intelligence Systems (IoTaIS), Internet of Things and Intelligence Systems (IoTaIS), 2021 IEEE International Conference On, 234-240. https://doi.org/10.1109/IoTaIS53735.2021.9628642 Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Arzteblatt international, 155(37), 611-620. https://doi.org/10.3238/arztebl.2018.0611 Yin, B., Teng, T., Tong, L., Li, X., Fan, L., Zhou, X., & Xie, P. (2021). Efficacy and acceptability of parent-only group cognitive-behavioral intervention for anxiety disorder treatment in children and adolescents: A meta-analysis of randomized controlled trials.doi:10.21203/rs.2.21666/v Proofreading, please.

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