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Focused SOAP Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect them to the classroom 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 couple of weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient
Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.. \"This must be a different patient from last SOAP assignment\"
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Focused SOAP Note and Patient Case Presentation
Subjective
CC: “I am not feeling safe around crowded places”
HPI: Harriet Osman is a 15-year-old girl Asian girl. The patient was here to evaluate her condition of stress after her abduction. She has currently prescribed counseling sessions with a professional counselor. In addition, she is prescribed for some drugs to relieve some minor injuries she received.
The patient came with a story of how a month ago a gang of armed people abducted her after they had attended a party away from their hometown. Besides, before then, she explained that her parents had a small conflict with their other family members, which would later turn into major inheritance disagreements and misunderstandings. The patient explained that she was having post-traumatic stress disorder and depressed about the series of events that were happening, which makes her no longer feel safe. The patient was having demotivation and a lot of fear of being in crowded places and more especially, with the other family members, just like where she was kidnapped (“Post-Traumatic stress disorder (PSTD) symptoms and causes,” 2020). The patient confessed to wanting to stay all alone and locked in the house not even wanting to go out. She was very anxious especially when strangers approached her for any reason.
Substance Current Use; the patient is currently not using any substance or hard drugs. Besides, she had not been using them before either.
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Medical History
Current Medications; the patient is currently utilizing some prescribed anti-depressants to reduce the rate of stress and depression attacking her. Additionally, due to the injuries she got from the inhumane handling by the goons, she is under medication for pain relievers and other antibiotics. It is very important to apply medication on injuries such as wounds to prevent infections.
Allergies; the patient has an allergic condition, especially on too much protein. To be specific, she is allergic to animal products such as cow's milk, eggs, and cow's milk-based formulas. These allergic conditions are becoming worse due to the fear and anxiety that she is experiencing from the trauma ("All About Allergies (for Parents) - Nemours KidsHealth", 2016). However, the allergy was managed using special drugs and protein avoidance.
Reproductive Hx; the 15-year old patient has an even menstrual cycle without any complications. She is neither pregnant nor lactating. She is not under any contraceptive use and she is not sexually active.
ROS
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GENERAL: The patient has lost some weight though not severe. She is not experiencing any fever, weakness, or fatigue.
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HEENT: She has not experienced any visual impairment, hearing impairment, or flu-like symptoms such as running nose and nose congestion. However, she has a sore throat, which is healing from the medications prescribed.
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SKIN: She has minor injuries and wounds on her skin. She has no rashes or itching.
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CARDIOVASCULAR: She has no chest pain, pressure, or discomfort associated either with any disease or to injury.
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RESPIRATORY: She has no respiratory complications by either short breath or cough.
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GASTROINTESTINAL: The patient is not experiencing any nausea issues, vomiting, and diarrhea. However, she has minor abdominal pains.
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GENITOURINARY: The patient is not having any genitourinary complications such as Burning on urination, odor, urine color, or any discharge.
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NEUROLOGICAL: The patient has no headache, dizziness, or numbness.
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MUSCULOSKELETAL: The patient is having minor muscle pains, joint and back pain resulting from poor handling.
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HEMATOLOGIC: She has no anemia neither is she bleeding.
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LYMPHATICS: The patient has no enlarged nodes.
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ENDOCRINOLOGIC: she has no reports irregular of sweating or feeling cold.
Objective:
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Diagnostic results: The doctor examined the patient by subjecting her to a physical exam to check for any medical complications. In addition, a psychological examination was done on the signs and symptoms and the events that led to them (“Post-Traumatic stress disorder (PSTD) symptoms and causes,” 2020), and, use of methods by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Assessment:
Mental Status Examination: The patient is a 15-year-old Asian girl. She looks young just like her age. She is calm and cooperative except for the developing phobia whenever she is around strangers. She is, however, cooperative and well presented. She is also neat and clean. She has no signs of any abnormal activity neither is she having bipolar signs such as unpredictable mood swings. In addition, she is quite fluent in her speech especially when she gets comfortable with her environment. She has clear thoughts and can explain everything as per how it happened. She has no hallucinations or illusion thinking. Her concentration is good and she is recovering.
Diagnostic Impression: A differential diagnosis is necessary since there may be more than one possibility for the diagnosis (Schimelpfening & Block, MD, 2020). To achieve this, the psychologist must find out to be sure that the patient's symptoms are genuine, rule out if there are drug-related causes, influence from illicit drugs, and general medical conditions. Lastly, the psychologist needs to define whether the patient is likely to have any impairment in the future from her mental disorder.
Reflections: In my opinion, post-traumatic stress disorder can be very depressing considering that the memories deny someone the freedom of movement, instill fear and anxiety in the patient. To prevent future mental problems, young children such as this one should be kept away from family disputes lest they be used as weak points to frustrate her family. They should not be involved in any violence for the sake of their young developing brains.
Case Formulation and Treatment Plan: For the treatment of post-traumatic mental disorders, they involve several procedures such as pharmacotherapy or psychotherapy. In case the patient is having some depression, anti-depressants are administered to the patient (Bhatt & Bienenfeld, 2019). Besides, the anti-depressants that are not approved by FDA such as nefazodone to treat certain anxiety disorders are also useful.
Besides, through controlled studies, behavioral therapy has been revealed to be efficient in stress treatment (Bhatt & Bienenfeld, 2019). However, depending on the assessment of the patient targets, and their response levels, some factors may determine her treatment and recovery outcome. These factors include the type of mental disorder, how severe the diagnosis is, support, treatment motivation levels, and the patient's ability to cooperate with the medical prescription.
Initiation of behavioral therapy to study her response and anti-depressants prescription. She was advised to visit a psychologist regularly for more examinations.
The patient was encouraged to continue with cranial electrotherapy approved by the FDA for treatment of anxiety, insomnia, and depression issues. The client has emergency numbers: Emergency Services 911, Client was instructed to go to the nearest ER or call 911 if they become actively traumatized and very anxious. The patient's questions were answered fully as she listened carefully. She appeared to understand the discussion and agreed to follow the treatment procedures as discussed.
Follow up with PCP as advised by the specialists.
The psychologist's examinations found out that the post-trauma disorder affecting the girl can be treated and she would regain her full freedom and esteem.
Return to the clinic: Continued treatment is medically necessary to address her mental conditions, stress symptoms, improve functioning, and prevent the need for a higher level of care.
References
All About Allergies (for Parents) - Nemours KidsHealth. Kidshealth.org. (2016). Retrieved 14 April 2021, from https://kidshealth.org/en/parents/allergy.html.
Bhatt, N., & Bienenfeld, D. (2019). Anxiety Disorders Treatment & Management: Approach Considerations, Pharmacotherapy for Anxiety and Panic Disorders, Psychotherapy for Anxiety and Panic Disorders. Emedicine.medscape.com. Retrieved 14 April 2021, from https://emedicine.medscape.com/article/286227-treatment.
Post-traumatic stress disorder (PTSD) - Symptoms and causes. Mayo Clinic. (2020). Retrieved 14 April 2021, from https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967.
Schimelpfening, N., & Block, MD, D. (2020). How Depression Is Diagnosed by Using Provisional or Differential Steps. Verywell Mind. Retrieved 14 April 2021, from https://www.verywellmind.com/provisional-diagnosis-vs-differential-diagnosis-1067284#:~:text=A%20differential%20diagnosis%20means%20that,lab%20tests%20to%20identify%20depression.
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