Alaina is an 85-year-old African American woman who lives alone with her small dog, Gus. Alaina lost her husband a few years ago after a painful battle with prostate can
Complete SOAP and PIE case notes for the following two cases.
- Alaina is an 85-year-old African American woman who lives alone with her small dog, Gus. Alaina lost her husband a few years ago after a painful battle with prostate cancer. Alaina and her husband had a wonderful, supportive relationship. Alaina cared for her husband throughout his illness, but it took a toll on her both physically and emotionally. She still struggles with grief over his death and has days where she still cries uncontrollably. Her family checks in on her often but struggle with knowing what to do on days she is experiencing deep sadness. Gus has been a great support for her and has been critical in helping her get through some of her hardest times. Alaina is aware of the changes that occurred over the years in the neighborhood where she has so many memories and enjoyed life for so long. Despite the increasing crime, she continues to feel safe in her home as she maintains relationships with her friends who live close by and with the support of her church family, who also check in on her weekly. Alaina has been experiencing some increased health problems recently. She suffers from back pains, osteoporosis, and diabetes. She has been prescribed several medications to manage her health issues and has been experiencing increased side effects due to the new medicines. Alaina works hard to maintain her daily routine, but her friends have noticed that she has started to engage in some unusual behaviors, such as walking without Gus or being out alone after dark, as well as self-report she has had some dizzy spells and was falling more. Her friends have shared their concerns with her children, and they have decided to meet with their mother to find out more information to determine how to best support her needs.
- George is brought to a community outpatient mental health clinic due to his parent’s observation that he is “not acting like a normal 13-year-old.” George’s parents report that he is failing school, has no peer group, and he is often angry at home, “lashing out at this younger brother and sister.” They brought him to the clinic because they think he is suffering from the same mental illness his mother has, and the last straw was that he was found with marijuana in his bedroom. The family reports a long and detailed family history of substance abuse. And they report that George’s mother lives with debilitating symptoms of anxiety and intermittent depressive episodes. When you talk to George, he reports “My parents are exaggerating. I have friends. And, my little brother and sister are annoying, and are always bothering me and stealing my stuff. Besides, I prefer hanging out by myself.
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