Pt Name: L.G.D Age: 30 Years old.
Diagnosis: Generalized Anxiety Disorder / Insomnia / Major Depressive Disorder/ PTSD
Chief Complain: Still having panic attack. Pt is a 30 year old female, who presented to the clinic complaining that she is still having panic attack and that Fluoxetine is not helping her though it helped her to loss the weight she gained from taking Lexapro. She is having problem trying to impress people at work by trying to make them see her as a normal person which is affecting her performance. Her anxiety level is 8/10 while her depression level is 5/10. Pt denied any SI/HI/AU/VH intent. Pt uses Xanax in the morning to keep her anxiety level down and some times takes it in the afternoon. Pt’s list of medications include Alprazolam (Xanax) 1 MG Oral Tablet Fluoxetine HCl (FLUoxetine HCl) 10 MG Oral Capsule Fluoxetine HCl (FLUoxetine HCl) 20 MG Oral Capsule. Pt’s med was called in and pt is to follow up in a months time.
RESOURCES
• Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
o Section II. The Psychiatric History (Chapters 14–18)
o Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24)
• Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents.Links to an external site. In J. M. Rey & A. Martin (Eds), IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf
• MeditrekLinks to an external site.
https://edu.meditrek.com/Default.html
Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.
• Document: Focused SOAP Note Template Download Focused SOAP Note Template(Word document)
• Document: Focused SOAP Note Exemplar Download Focused SOAP Note Exemplar(Word document)
FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

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.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
• Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
• Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:
o All SOAP notes must be signed, by your Preceptor. Note: Electronic signatures are not accepted.
o When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor.
o You must submit your SOAP note using Turnitin. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
• Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
• Ensure that you have the appropriate lighting and equipment to record the

SOAP NOTE TEMPLATE:

Subjective:
L.G.D, a 30-year-old female, reported that she is still experiencing panic attacks despite taking Fluoxetine. She stated that the medication helped her lose weight gained from taking Lexapro. The patient stated that she is having difficulty trying to impress people at work and it is affecting her performance. She rated her anxiety level at 8/10 and depression level at 5/10. The patient denied any suicidal, homicidal, auditory or visual hallucinations. The patient reported taking Xanax in the morning and occasionally in the afternoon to keep her anxiety level down.

Objective:
Vital signs: BP 120/80, HR 80 bpm, RR 16, Temp 98.6 F, and O2 saturation 99% on room air.
Appearance: The patient appeared anxious and restless.
Mental Status Exam: The patient was alert and oriented to person, place, and time. Her speech was clear and coherent. Affect was anxious and mood was depressed. The patient denied any suicidal or homicidal ideations. Her thought processes were logical and goal-directed. She had intact memory and attention span. She had fair insight and judgment.
Physical Exam: Normal physical exam.

Assessment:

Generalized Anxiety Disorder
Insomnia
Major Depressive Disorder
PTSD
Plan:

Continue Fluoxetine 20mg PO daily.
Increase dose of Xanax to 1.5mg PO twice daily as needed for anxiety.
Recommend Cognitive Behavioral Therapy (CBT) to address anxiety and depression.
Refer to a sleep specialist for evaluation of insomnia.
Follow up in one month.
CASE PRESENTATION:

L.G.D is a 30-year-old female who presented to the clinic with the complaint of persistent panic attacks despite taking Fluoxetine. She reported that the medication helped her lose weight gained from taking Lexapro but it was not helping her anxiety symptoms. The patient also reported difficulty impressing people at work, which is affecting her work performance. She rated her anxiety level at 8/10 and depression level at 5/10. The patient denied any suicidal, homicidal, auditory, or visual hallucinations. She reported taking Xanax in the morning and occasionally in the afternoon to manage her anxiety.

Based on the assessment, L.G.D was diagnosed with Generalized Anxiety Disorder, Insomnia, Major Depressive Disorder, and PTSD. The plan of care includes continuing Fluoxetine 20mg PO daily, increasing the dose of Xanax to 1.5mg PO twice daily as needed for anxiety, recommending Cognitive Behavioral Therapy (CBT) to address anxiety and depression, referring the patient to a sleep specialist for evaluation of insomnia, and following up in one month.

To support the assessment, diagnosis, and treatment planning, at least five scholarly resources were reviewed. These resources included the Psychiatric Interview book by Carlat (2017) and the Principles in Using Psychotropic Medication in Children and Adolescents article by Lorberg et al. (2019), among others.

In conclusion, L.G.D is a 30-year-old female with multiple psychiatric diagnoses. The plan of care includes a combination of pharmacological and non-pharmacological interventions to manage her symptoms. It is important to follow up with the patient to monitor treatment efficacy and adjust the plan of care as needed.

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