Psychiatric Diagnostic Evaluation

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your other courses. 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 during the last four weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
Assignment:
• Select an adult patient that you examined during the last 4 weeks. (Writer: See subject patient info below)
• Create a Focused SOAP Note on this patient using the template provided. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
• Include at least four – five scholarly resources to support your assessment, diagnosis, and treatment planning.

*Note to Writer: You may use below “Patient’s” information and create addtl’ information as needed to complete assignment to the fullest.
• Include at least four (4) – 5 (five) scholarly resources to support your assessment and diagnostic reasoning.

Patient:
Dx: Anxiety, Insomnia, 90791 Psychiatric Diagnostic evaluation: N4
The patient is a 65-year-old female who presents today for an initial consultation. he is seen for anxiety. His PCP was prescribing Lorazepam 1 mg daily for several years before recommending referral to Psychiatry since his anxiety hasn’t improved. He endorsed a long history of anxiety for several years without triggers. The patient stated he worked in construction for many years before retiring.
He has no friends besides his neighbor, whom he talks to occasionally. He lives with his family but likes to stay alone.
Medical Hx: HTN, Hyperlipidemia, and chronic bilateral leg pain
Medication
-Lorazepam0.5 mg 1 tab daily
-Hydroxyzine 50 mg 1 tab PO nightly
-Buspirone 5 mg 1 tab PO Daily

Plan-
-Continue Current Meds
-Continue patient counseling with the therapist
-F/U in 4 wks

Resources to consider:
• Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

o Chapter 10, “Stimulants and Other Meds for ADHD”
o Chapter 13, “Natural Medications in Psychiatry” (pp. 147–148 only)
o Chapter 14, “Dementia”
• Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
o Chapter 28, “Assessing Neurocognitive Disorders (Dementia and Delirium)”

• Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

NOTE: Please use Resources/References not older than 5-years. (2019 – 2024)