Unit 4 Assignment - Depression & Anxiety Case Study
Complete a full intake on this patient and then develop a treatment plan using the template offered.
The patient is a 59-year-old married woman with 5 grown children
She is moderately overweight (BMI 30) and was diagnosed with non-insulin-dependent diabetes 10 years ago; she is fairly well managed on an oral hypoglycemic medication (glipizide 10 mg twice per day)
Two years ago, the patient experienced 2 tremendous stressors: her oldest child developed leukemia (now in remission), and her mother and father both passed away
She suffered a significant and impairing major depressive episode that went untreated until recently
This was her fifth episode of depression; she experienced 2 major depressive episodes as a teenager, and she developed postpartum depression and anxiety following the births of 2 of her children
Four months ago, after she was too fatigued to get out of bed, she sought treatment for the first time in her life
After receiving education and support from her clinician, she reluctantly agreed to take Paxil 30 mg/day
The patient has experienced a near-complete resolution of her symptoms in the last 6 months; however, she has developed side effects and wants to discontinue the medication
Specifically, she has increased appetite and has correspondingly gained 7 pounds in the last 4 months, with an increase in HgA1c of 1 full percentage point
She also reports excess daytime sedation and anorgasmia (very unusual for her)
What options can you offer to manage these side effects? Be specific
What education should you give the patient about stopping this medication abruptly?
What is your treatment plan?
There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
consent given to patient about psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent obtained. Patient
Gender Identifier Note:
Pertinent history in record and from patient: X
During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.
Patient does not
report hallucinations, delusions, obsessions or compulsions. Patient’s
HI/ AV: Patient currently
(medication & food)
Past Medical Hx:
Past Psychiatric Hx:
Previous medication trials:
History of Violence to Self: none reported
History of Violence to Others: none reported
Mental health treatment history discussed:
History of outpatient treatment:
Previous psychiatric hospitalizations:
Current Medications: No current medications.
Past Psych Med Trials:
Family Medical Hx:
Family Psychiatric Hx:
Military service History: Denies previous military hx.
Education history: completed HS and vocational certificate
Developmental History: no significant details reported.
Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo.
Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview.
, Past Medical and Psychiatric History,
Current Medications, Previous Psych Med trials,
Social History, Family History.
Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”
Vital Signs: Stable
is cooperative and conversant,
appears without acute distress, and fully oriented x 4. Patient is dressed
This is where the “facts” are located.
**Physical Exam (if performed, will not be performed every visit in every setting)
Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.
DSM5 Diagnosis: with ICD-10 codes
Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
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