Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Focused SOAP notes, such
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
T.P is a 37-year-old African American female who was referred from DCH where she was admitted for ETOH detox. Client was found to be depressed and anxious, she is a mother of 7 year old son, history of ETOH abuse since early twenties. Used to drink heavy after the death of her father 13 years ago, drinks 3 to 4 glasses of liquor per day, but for the past 3-4 years she has been drinking half bottle of wine 4 to 5 times a week. Was hospitalized for 3 days two months ago for detox , was treated by PCP for depression and anxiety with Zoloft 25mg po daily, Remeron 15mg po QHS and Xanax 1 mg po daily prn for 1 year. Feels lonely, sad, depressed, anxious, gets overwhelmed, crying spells, low energy, low motivation, hard to motivate even to go to work, gets nervous when around people. Said she drinks ETOH to numb feelings. Endorsed history of anxiety attack, denies any suicidalor homicidal thoughts, no hallucination, claims Remeron helps her to sleep and increase her appetite but she ran out 10 days ago and has not been sleeping well and does not have appetite. Client said she feels like Zoloft and Xanax are not doing anything for her. Diagnosis are Major depressive disorder, recurrent, moderate (F33.1) and ETOH use disorder severePlan: Increase Zoloft to 50mg po daily, continue Remeron 15mg po QHS, increase Xanax to. 1mg BID, referral to see a psychotherapist for individual therapy, continue AA meeting and return for follow up in two weeks.
USE this Diagnostic
Diagnostic results:
F10.1 - ALCOHOL ABUSE
F41.1- Generalized Anxiety Disorder
F32.A Depression, unspecified
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