Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
My patient:
Patient is a 42 year old female who presents to the office for medication management. She is married with two children. She works as an accountant for the public school system. She has a great fear of public speaking, which she has to do for her job. She reports good sleep and appetite lately, which is improved from previous visits where she was not sleeping due to the fear of public speaking and the stress of her job. She also reported at previous visits that for months she was always feeling keyed up and tense, restless. She found it difficult to work because of the fear of speaking at her job. It was affecting her everyday mood and causing conflict at home. She felt as though she was spiriling out of control. Since starting medications, she is doing much better. She rates her mood 8/10 today. She denies any SI/HI/AVH. No delusions, mania or psychosis elicitied. She does not have any medical history and no history of substance abuse. Medication trials- Lexapro, Xanax. Current medications- Propranolol, Lamotrigine, Hydroxyzine. No allergies to food or medications. ROS- all negative. Her anxiety and mood are well managed by medications and therapy. Labs- CBC, CMP, TSH, Lipids, all normal. MSE- euthymic mood and euthymic affect, normal speech rate and volume, linear thought process, proper hygiene and dress. Good insight and judgment. Memory normal. Differentials- Generalized anxiety disorder, panic disorder, bipolar I disorder.
Diagnosis- Bipolar I d/o, moderate, with anxious distress, Insomnia with mental d/o, persistent.
