6665 P Wk9: Focused SOAP Note On A Client With GAD.
DO NOT ADD A REVIEW OF SYSTEMS (ROS) TO THIS PAPER. Patient info: Name – TT; Age – 19. Caucasian female. Medication: Wellbutrin SR 100 mg tab. Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? (You have to make it up). Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why?
Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms. Include penitent positive and penitent negative symptoms noted in the patient for each differential diagnosis (THIS PART IS VERY IMPORTANT IN THIS PAPER). Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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. Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
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