Use 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?  Focused SOAP Note PTSD Essay Examples
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?
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be

Patient Information

Patient Initials: A.P               Age: 14 years              Gender: Female

Subjective

Chief Complaint: “Nearly every night, I have a nightmare in which I am lost and unable to find my parents.”

HPI: A.P is a 14-year-old girl accompanied by her father who presents with complaint of frequent nightmares in which she is lost and is unable to find her parents. She claims that she has trouble falling asleep in the dark since she has vivid nightmares at such times. As a result, she sleeps with the lights on. The father reports that A.P also does not like going to school because she does not want to associate with people and prefers to be alone. Her father also brings up the fact that A.P.’s teacher often expresses concern with her inability to concentrate in class. A.P. also complains of occasional headaches, reduced appetite, and difficulty falling asleep. She also reports constantly thinking about the death of her best friend’s parents who were involved in a car accident two years ago. Focused SOAP Note PTSD Essay Examples

Current Medications: None

Allergies: NKA

Past Medical History: Denies history of illnesses or hospitalizations.

Past Surgical History: No history of major or minor surgery.

Past Immunization History: All immunizations are current

Past Psychiatric History: Denies history of mental disorders

Past and Current Substance Use: Denies past and current use of alcohol, tobacco, or illicit drugs.

Psychological History: Patient lives with her parents and grandparents. She attends the school, but she has little desire to interact with the other students. Her father claims that she is quick to become furious and might potentially cause problems when she is around people. Watching movies are one of her favorite things to do in her spare time.

Family Psychiatric History: no history of mental disorders in the family.

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Objective

Mental Status Exam

A.P appears sad and distressed. She is well-dressed with fair grooming. She is alert and oriented x4.  Her attention span is limited. Her mood is dull while her affect is flat. She is cooperative, but fails to maintain eye contact. She does not demonstrate any signs of being agitated or restless. There are no abnormalities in her motor function. Her gait is steady, and she maintains an upright posture. A.P has a low pitch in her speech and a difficult time speaking fluently. She had moments when she would demonstrate verbal disorientation by mixing up the words she was saying. Her behavioral and social functions are significantly impaired. She maintains that she would rather be by herself at school and does not want to engage with her other students. Her judgments appear somewhat impaired. Her memory, both short-term and long-term, are intact. She displays a lack of insight into the alterations in her behavior. She denies suicidal ideation, delusions or auditory hallucinations.

Assessment

The results of A.P’s mental status assessment shows that she exhibits certain abnormal mental characteristics, such as excessive worry, a dull mood, impaired insight and judgment, and an insufficient attention. Due to the presence of these symptoms, it is likely that she is having a psychiatric condition.

Differential Diagnosis

·         Posttraumatic Stress Disorder (PTSD) F43.1: This is a mental health disease that may be brought on by either personally experiencing a dreadful incident or seeing another person going through it. A person suffering from PTSD can have flashbacks, nightmares, intense worry, and uncontrolled thoughts about the traumatic incident (Carvajal, 2018).  The criteria for PTSD according to the DSM-5 is encounter with a traumatic incident and evidence of symptoms that fall into four domains, including intrusion, avoidance, unpleasant shifts in mood and thoughts and, and shifts in reactivity and arousal. The majority of criteria for PTSD in DSM-5 are met by A.P. She was subjected to a traumatic experience which is the death of her best friend’s parents. She also has additional symptoms, such as having nightmares, being too worried, having trouble sleeping, and having difficulty concentrating. As such, PTSD is the most likely diagnosis for her.

• Acute Stress Disorder 0: Acute stress disorder, often known as ASD, is a severe and distressing response that manifests itself in the weeks immediately after exposure to a traumatic incident (Bryant, 2018). The duration of symptoms is normally no more than one month. According to the DSM-V criteria, a person must have witnessed a traumatic incident in addition to having accompanying symptoms such as intrusion, unpleasant mood, dissociation, avoidance, and reactivity, as well as severe distress. Diagnosis of this disorder requires a high degree of severity of symptoms. Most of these symptoms are exhibited by A.P, but the fact that the onset of acute stress disorder is from three days to a month after exposure rules out this diagnosis.
• General Anxiety Disorder (GAD) 1: This disorder is characterized by abnormally high levels of worry and anxiety over ordinary aspects of daily life for which there is no clear explanation. According to the DSM-V, the criteria for GAD is having excessive anxiety and concern about a variety of events or activities over a period of at least six months and the inability to keep the worry under control (Maron & Nutt, 2017). A.P matches the criteria for GAD; nevertheless, GAD is not often linked with nightmares, which were her primary source of distress. Therefore, GAD is ruled out. Focused SOAP Note PTSD Essay Examples

Plan

Pharmacotherapy

The current treatment guidelines stipulate that SSRIs are the first-line treatment for PTSD. Only the antidepressants sertraline and paroxetine have been granted approval by the FDA for treatment of PTSD (Ostacher et al., 2020). For A.P, I would prescribe Sertraline 50mg once daily and increase the dosage gradually to a maximum of 200mg daily if she responds well to the medication.

Alternative Treatments

Cognitive behavioral therapy is an alternative treatment option for this patient. Because it may assist a person in understanding and challenging problematic thinking processes and feelings brought on by PTSD, cognitive behavioral therapy may be useful in the treatment of the disorder (Ostacher et al., 2020).

Health Promotion and Patient Education

A health promotion activity for this patient would be to guide her father on how to help her avoid intrusions and teach her how to control worries and anxiety so that he can live a normal life.

The patient education aspects in this case would include compliance with the medication regimen and practicing of coping skills that reduce fear and worry.

Follow-up

The patient is to follow up in 4 weeks for progress evaluation.

Reflections

I feel that I implemented all of the essential interventions to address this patient’s condition. As such, there is nothing about the session that I would do differently if I had the opportunity to perform it again. I was able to conduct a follow-up with the patient and found that her symptoms had improved. As such, the interventions were successful.

References

Bryant R. A. (2018). The Current Evidence for Acute Stress Disorder. Current psychiatry reports, 20(12), 111. https://doi.org/10.1007/s11920-018-0976-x

Carvajal C. (2018). Posttraumatic stress disorder as a diagnostic entity – clinical perspectives. Dialogues in clinical neuroscience, 20(3), 161–168. https://doi.org/10.31887/DCNS.2018.20.3/ccarvajal

Maron, E., & Nutt, D. (2017). Biological markers of generalized anxiety disorder. Dialogues in clinical neuroscience, 19(2), 147–158. https://doi.org/10.31887/DCNS.2017.19.2/dnutt

Ostacher, M. J., & Cifu, A. S. (2019). Management of posttraumatic stress disorder. Jama, 321(2), 200-201. https://doi.org/10.1001/jama.2018.1929

Focused SOAP Note PTSD Essay Examples