05 May Describe a new experience, significant event/patient interaction, never seen before diagnosis, etc. that you have experienced?in clinical this week. You can choose the same ca
Describe a new experience, significant event/patient interaction, never seen before diagnosis, etc. that you have experienced in clinical this week. You can choose the same case you used for your SOAP Note this week if that case had an effect on you. Discuss the impact this had on you in terms of increasing your understanding of the PMHNP role, psychopathology and/or the provider-patient relationship. Explore your personal strengths and limitations and their effect on the provider/patient relationship. Include reflection on your therapeutic use of self. Your discussion should reflect your specific learning/insight. Identify something specific that you learned from reflecting on this event/interaction and tell how you will apply that learning in your future practice.
Someone between age 1-17 with psychiatric mental health disorder
Choose a patient between age 1-17 with a psychiatric mental health disorder and formulate a soap note using this template. This is only an example.
Patient Name: AD
Accompanied by: Brother
CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago
HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits, any abnormal labs?
Any health screening tools used?????
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.
A – with (ICD-10 code)
1. choose 3 differential diagnoses
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1
P- Continue Fluoxetine increasing dose to 20mg.
Continue outpatient counseling: partial inpatient program continued with individual and group sessions
Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time
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