Anxiety Disorder, Post-traumatic stress disorder (PTSD)
A 33-year-old Hispanic male patient with history of GAD and PTSD. Patient is a referral from his private doctor for increase anxiety and insomnia. The patient report he was assaulted 3 months ago by two males and that his vehicle was stolen. Patient reported that due his injuries he must stay in the hospital for 7 days. Patient report that after the incident his live change completely and still affecting his daily activities. Patient also stated that he is suffering from insomnia. The patient appears awake, alert, and oriented x 4 and dressed appropriately with good hygiene and good eye contact. He presents with spontaneous speech, regular rate, and volume, relevant, and coherent. His mood is anxious, and his affect is mood congruent. The thought process seems concrete. Patient-reported feeling more secure. Throughout the session, the patient actively participated and provided insightful responses. The patient was able to discuss psychosocial stressors and coping skills openly. The clinician provided psychoeducation regarding medication compliance, and the patient was receptive. The patient was encouraged to continue follow-up psychotherapy to monitor his anxiety. Individual psychotherapy is scheduled in two weeks.
Assignment 2: Focused SOAP Note and Patient Case Presentation
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.
• Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; 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.
• Specifically address the following for the patient, using your SOAP note as a guide:
• 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: 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?