For this Assignment, you will document information about a patient.Focused SOAP Note Template provided. You will then use this note to develop and record a case pr

Subjective:

CC (chief complaint): snice I separated from my husband people have been following me around

HPI: O.A is a 72-year-old African American female who came in for psychiatric evaluation for anxiety and people following her around. client is a retired home health care aid and was referred by her PCP for psychiatric evaluation and follow up. Client report that she is separated from her husband because her husband had affair and she had to leave him, he was causing a lot of trouble for her, he was spraying things in the house so she will get sick , she had to call police 2 to 3 times, then people started following her everywhere watching her going to store, few times she tried to drive away from them b/c they were chasing her with car. Client report that she finally left home and is living with her daughter now. Client said her problem started about 1 year ago, she was married to her husband for 30 years and separated one year ago. She saw a doctor 2 months ago, was given Risperidone 0.25 mg daily, she took it but it did not help, then she went to Canada with her cousin who took her to see psychiatrist there and she was given Abilify 2 mg QAM and 5 mg QHS which she is taking for 4 weeks now and she feels better, not anxious that much, and people are not following her as much, but still believes they follow her, claims her husband had asked these people to follow her. Client said she is sleeping well, appetite is good, denied any suicidal or homicidal thoughts, denied any hallucination. Diagnosis is unspecified psychosis not due to a substance or known physiological condition [f29] Plan is for client to continue Abilify 2.5 mg po QAM and 5 mg po QHS since she seems to be responding well to Abilify and return for follow up in one month.

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:

USE this Diagnostic   DSM-5 diagnostic criteria

· Psychosis not due to a substance or known physiological condition [f29]

· F41.9 Anxiety disorder. Unspecified

· F 31. 9 Bipolar disorder, unspecified

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

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