Case 2 & SOAP :Psychiatric Assessment Paper
Base on the media, develop a focused SOAP Note, including differential diagnosis and critical-thinking process to formulate a primary diagnosis.
Additional information for the case presentation: The patient presents with bright vibrant colored clothing and heavy makeup. She had disheveled long hair, was unkept.
Temp 98.2 Pulse 90 Respiration 18 B/P 138/88
Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H) Case 2 & SOAP :Psychiatric Assessment Paper .
Incorporate the following into your responses in the template:
- Subjective: What details did the patient provide regarding their chief complaint and symptomatology 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?
- Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Case 2 & SOAP :Psychiatric Assessment Paper .Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
- Reflection notes: What would you do differently with this client if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). Case 2 & SOAP :Psychiatric Assessment Paper .
- provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
- Current Medications:
- Allergies:
- Reproductive Hx:
ROS:
- GENERAL:
- HEENT:
- SKIN:
- CARDIOVASCULAR:
- RESPIRATORY:
- GASTROINTESTINAL:
- GENITOURINARY:
- NEUROLOGICAL:
- MUSCULOSKELETAL:
- HEMATOLOGIC:
- LYMPHATICS:
- ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
Case 2 & SOAP :Psychiatric Assessment Paper