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UTRGV Female Patient Sleeping Problems Case Study

UTRGV Female Patient Sleeping Problems Case Study

Question Description

aymelea (hidden)

i need help with my soap notes. i need about 8 a/ day

they are like 1/4 summaries of patient’s encounters.

i will teach you how to do it

I ma in 3 different programs at the same time … overwhelmed

lm

40 mins ago

ProfHenryM

I will be glad to help

Are the needed soap notes from case studies or?

But maybe you could also attach some examples

39 mins ago

aymelea (hidden)

we have to invent them, create cases then facked the the therapy acccordingly…

37 mins ago

Sample note one

Clinical Notes
Psychiatry follow-up SOAP note
S- Subjective: Pt presents for medication follow up. Pt states, ” I feel fine except I have more financial stress” Pt sleeps is poor 3-4 hours interrupted. Pt denies any side effects. Pt states anxiety level is a 7/10 and depression 6/10. Pt states she is sleeping more during the day. Pt saw movement specialist and told she did not have Parkinson.
O- Vitals: T97.8 , P70 , R20 , BP124/90
General: AAOX3 to person, place, and time.
Mental Status Exam
General Observations
Appearance-
Speech-
Behavior-
Cooperativeness-
Thinking-
Thought Process-
Thought Content-
Perceptions-
Emotion-
Mood-
Affect-
Cognition-
Orientation/Attention-
Memory-
Insight-
Judgment-
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally posteriorly
Skin- no lesions or rashes
Labs: CBC, CMP, and TSH all within normal limits
A- F60.1 Schizoaffective
F31.9 Bipolar Type
F90.0 ADHD
F41.1 GAD
P-1. Continue Vitamin D 50,000 iu 1 po q w, #4, 6 refills
2. Continue to Rexulti 2.5 mg 1 po q d, #30, 2 refills
Activating AIMS 2/28/2019 = 5 (jittery leg movement, being treated for Parkinson’s by the neurologist, oral facial tongue movements noted)
Continued downward titration
3. Continue Klonopin 0.5mg 1-2 tabs po qd prn #60, 0 refill
4. Continue Ativan 0.5mg 1 po q hs prn, #30, 0 refills
5. Continue Zofran/Oneansetron 8mg sl up to tid prn, #120 for nausea 1 refills
6. INCREASE Trintillex 10 mg po qd #30, 3 refills
7. Will consider Austedo at next visit.
8. RTO in [ 4 ] weeks
9. Encouraged by PMHNP-BC to continue with therapist/counselor/social worker/psychologist and/or referred to therapist/counselor/social worker/psychologist.

35 mins ago

Sample two

S: JO is an 8- year- old male, enrolled in 3rd grade diagnosed with ADHD, Oppositional defiant disorder and Adjustment Disorder. He came in for follow up and renewal of medications. He is taking Concerta 27 mg daily. His Mom is happy with the medication. There are no bad reports from school and is getting high grades in class. He denies depression, aggression is at a level 2, anxiety at a level 1. He denies suicidal ideations, hallucinations or delusions. He sleeps all night and denies nightmares. He has a good appetite.
O: Vital signs are stable and overweight for age. Height is 4’0” and weighs 50 pounds (BMI 15.3 = Normal)
Head, Eye, Ear, Nose and Throat Exam: unremarkable findings
CV: Normal exam with regular heart rate, clear heart sounds, no murmurs.
Lungs: Clear to auscultation, without wheezing or diminished breath sounds
Abdomen: flat, soft, non-tender
Extremities: no deformities noted
Mental Status:
JO is alert and talkative.
Speech, normal rate, volume, and tone.
Willingly engages in eye contact.
No hesitancy in speech.
Short term recall is grossly intact.
Oriented to person, time and place.
Concentration normal.
Thought processes logical and sequential.
He denies aggression, depression, and anxiety is at a level 5.
He denies hallucinations or delusions.
His mood is congruent with affect.
Rapport well established.
A: Attention-deficit hyperactivity disorder, predominantly hyperactive type F90.1
Adjustment Disorder with Anxiety F43.22
Oppositional defiant disorder F91.3
P: continue Concerta 27 mg daily
continue counseling
Follow up after in 1 month


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