Hi there, I needed help writing an assignment. For a Nursing course of Psychiatric for nurse practitioners. Masters level. I have to write a SOAP NOTE for a patient I seen, scholarly written, APA formatted, and referenced. A minimum of 4 references are required past 10-years. Please include DIO with references.
Sellier, Veronica
Date of birth, 02/07/19831
Date of service: 8/29/23
42y old female
CC: “Anxious, exhausted, difficulty with focus and concentration, dealing with Lyme & aftermath.”
HPI: Veronica continues to deal w/Lyme-related sx such as memory loss & physical pains. Recently recovered from visible shingles on her face which permanently damaged her left eye. Doesn’t feel her first Doxycycline round was effective. Appt w/PCP tomorrow when she thinks he’ll order a brain MRI to evaluate a tumor possibility. Discussed her fears about what may be found. She hasn’t taken Vyvanse this month due to extreme fatigue.
Pertinent Past Medical, Psychiatric, Family & Social History: Psychosocial History: Psychosocial History: Married to very emotionally supportive Sten. They have 2 daughters and 1 son, ages 4-11 in private school. Good relationship with her mother and Sten’s family.
Current Living Situation/Psychosocial Stressors: Lives with Sten and their children.
Trauma History: past emotional abuse and neglect by her father
Current Living Situation/Psychosocial Stressors: Lives in a college dorm during the school year, otherwise, she lives with her parents.
Trauma History: Denied
Past Psychiatric mediction: Paxil, Decreased pre-menstrual Symptoms , None remembered, Symptoms resolved,
Past psychiatric treatments: 5/2023: started EMDR
Assessment:
GAD-7 = 17
PHQ-9 = 15
Denies suicidal or homicidal ideas. Mood “OK”, affect is full and appropriate. Appropriate dress, appropriate grooming and hygiene, appears stated age. No acute distress. Modified for telehealth; seated, upright posture, extension of arms. No abnormal movements. Alert and oriented to person, place, time and situation. No abnormal thought content, no auditory or visual hallucinations, no paranoid ideations or delusions. Attention span is intact. Judgment is not impaired.
Current diagnoses: F41.1 GENERALIZED ANXIETY DISORDER,
F90.2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, COMBINED TYPE
And F33.41 MAJOR DEPRESSIVE DISORDER, RECURRENT, IN PARTIAL REMISSION.
Differential diagnosis:
1. Bipolar disorder
2. Seasonal affective disorder
3. Adjustment disorder
Primary diagnosis: Adjustment disorder
Plan/ Follow-up:
Medication continues: Wellbutrin XL 150 mg daily, L-Methylfolate 15 mg daily.
PRN Medication: Adderall IR 10 mg afternoons, Xanax 0.25 daily
Lifestyle/Behavior Modification: time for self, healthy calorie dense meals/snacks
Adjunct Treatment: Weekly psychotherapy, EMDR
Collaborate with: PCP
If symptoms do not improve or recur, possibly consider: Ritalin
Follow up on 10/23/2023 at 12:00 and prn
Patient Instruction/Education Provided: Above verbally discussed with Veronica
Hi there, I needed help writing an assignment. For a Nursing course of Psychiatr
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