Psychiatric Healthcare

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your other 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 four weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Assignment:
• Select an adult patient that you examined during the last 4 weeks. (Writer: See subject patient info below)
• Create a Focused SOAP Note on this patient using the template provided. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
• Include at least four – five scholarly resources to support your assessment, diagnosis, and treatment planning.

*Note to Writer: You may use below “Patient’s” information and create addtl’ information as needed to complete assignment to the fullest.
• Include at least four (4) – 5 (five) scholarly resources to support your assessment and diagnostic reasoning.

Patient:
Initial visit
Source of Referral: Others Ethnicity: Mid-Eastern
Informant: Patient
Interpreter: Yes
Language: Arabic
Interpreter Name: Daughter
Chief Complaint
“I suffer from depression stemming from War in Iraq. My PCP is treating me for depression, but the medications aren’t effective.”
History of Presenting Problem: The pt. is a 65 yrs. old female seen for an initial consultation.
Session interpreted by her daughter.
Medication- Seroquel 25 mg- She was taking Seroquel 50 mg but was reduced due to abdominal discomfort.
Sertraline 50 mg daily and another 100 mg HS- She was advised to take both in the morning.
Meclizine 25 mg daily.
Nightmare from war in Iraq. She reports depression stemming from previous war experiences and divorced in 2007 and not in any relationship. She has no friends and feels language barriers impacts her ability to build a healthy relationship. She has been in the US since 2015. She tried ESA class but failed.
She will be referred to therapist.
She was a teacher in Iraq. Suggested to begin Arabic tutoring class, but her daughter reports that she has been forgetful and less motivated.
Rated depression 10/10.
She has 3 daughters- 26, 29, and 30 yrs.
She denies SI, HI, AH, and VH
Plan- Refer to Therapy
Medications- Continue Seroquel 25 mg HS
Medication- Sertraline 100 mg
Added- Wellbutrin SR 100 mg daily.
Referred to Chief Psychiatrist for Immigration Waiver
She failed immigration interview due to language barrier and Anxiety.
F/u in 2 weeks
Past Psychiatric History
MDD: Yes, Interest, Lost, Energy, Lack of, Concentration, Decreased Appetite Changes and Sleep Changes
Dysthymia: No
Mania/hypomania: No
AH: No
VH: No
Paranoid: No
DOC: No
IOR: No
GAD: Yes
Panic Episode: No
OCD: No
PTSD: Yes
Eating DO: No
Self-Mutilation: No
Suicide Attempt: No
Past Psych Rx Trials: No
Other Treatments: No
Substance Use History: No
Rehab/Programs: No
Family Psych History
Mental Illness: No
Suicide: No
Substance Abuse: No
Past Medical History
Others: Wears Hearing Aid
Pregnant: No
Breastfeeding: No
Medication Allergies: NKDA
Outside Records available for review: No
Psycho Social History
Employed: No
Worker’s Comp: No
Legal: No
Marital History: Divorced
Number of Children: 3
Social Support: Family
Mental Status Examination
Appearance: Clean/Neat
Grooming: Good
Attire: Appropriate
Assistive: None
Behavior: Cooperative
Eye Contact: Adequate
Speech: NRRT
Affect: Stable
Thought Process: Linear
Internally Pre-occupied?: No
Suicidal Ideation: No
Homicidal Ideation: No
Orientation: Person, Place and Date/time
Judgment: Intact
Insight: Good/true
Recent and Remote Memory: Good
Attention Span and Concentration: Good
Language & Computation: Good
Fundamentals of Knowledge: Good
Abstract Reasoning: Good
Assessment Working Diagnosis
Axis I Diagnosis:
F32.A : Depression, unspecified
F41.9 : Anxiety disorder, unspecified
F43.10 : Post-traumatic stress disorder, unspecified

Axis IV Psych & Environmental Problems: Social environment
Axis V Global Assessment Current: 51-60
Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers ).
Treatment Plan
Medication Mgt: Seroquel 25 mg HS, Wellbutrin SR 100 mg daily, Sertraline 100 mg daily , and Prazosin 1 mg HS

Plans
Reviewed crisis intervention plans including ER/911 options for acute psychiatric/medical issues. The patient was instructed to notify staff on-call after hours or go to the ER for adverse effects and/or allergic reactions. Patient verbalized understanding of information and opportunity to ask question and address concerns.
Provided psycho-education and support therapy to: Patient
Encourage continuing other ongoing Tx with: PCP and Therapist
Medication Management:
New Prescription/s started?: Yes
Discussed r/b, s/e profile of medications with pt. Informed consent obtained: Verbally
Additional Demographics
prazosin 1mg 1 capsule by mouth NIGHTLY 30 Day(s) 30 1
Wellbutrin SR 100mg 1 tablet by mouth DAILY 30 Day(s) 30 1
Current Encounter Diagnosis
F32.A – Depression, unspecified
F41.9 – Anxiety disorder, unspecified
F43.10 – Post-traumatic stress disorder, unspecified

Resources to consider:
• Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

o Chapter 10, “Stimulants and Other Meds for ADHD”
o Chapter 13, “Natural Medications in Psychiatry” (pp. 147–148 only)
o Chapter 14, “Dementia”
• Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
o Chapter 28, “Assessing Neurocognitive Disorders (Dementia and Delirium)”

• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

NOTE: Please use Resources/References not older than 5-years. (Late 2018/2019 – 2023)