Treatment plan: SOAP 1: Demographics: 37-year-old female, divorced, employed part-time, lives with her two children. Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine. Reason for Visit: Evaluation

SOAP 1:

Demographics: 37-year-old female, divorced, employed part-time, lives with her two children.

Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.

Reason for Visit: Evaluation of trauma-related symptoms, worsening depression, and sleep disturbances.

Chief Complaint: “I keep reliving things that happened to me when I was younger. I'm depressed, exhausted, and can't sleep.”

Psychiatric Diagnoses:

·        Post-traumatic stress disorder (F43.10)

·        Major depressive disorder, recurrent, moderate (F33.1)

Medical Comorbidities: Asthma and GERD.

Current Medications: Albuterol inhaler PRN and Omeprazole 20 mg daily. No current psychiatric medications.

Social Problems: Childhood trauma, history of abusive relationships, financial stress, single parenting, and limited social support.

Procedures: Comprehensive psychiatric evaluation, MSE, trauma history assessment, PTSD and depression screening, sleep assessment, medication reconciliation, substance-use screening, and suicide risk assessment.

Clinical Note: Patient reports intrusive memories, recurrent nightmares, hypervigilance, exaggerated startle response, and avoidance behaviors related to childhood physical abuse. Also endorses depressed mood, anhedonia, fatigue, feelings of worthlessness, and difficulty concentrating for the past four months. Reports sleeping approximately 4–5 hours nightly. Denies mania, psychosis, substance misuse, SI, or HI.

S (Subjective): Reports persistent sadness, nightmares, flashbacks, poor sleep, low motivation, and social withdrawal. States symptoms interfere with parenting and occupational functioning.

O (Objective): Alert and oriented ×4, appropriately groomed, cooperative. Mood depressed; affect constricted. Speech normal, thought process linear. No psychosis or SI/HI. Insight and judgment fair.

A (Assessment): PTSD with persistent trauma-related symptoms and comorbid recurrent moderate MDD. Significant psychosocial stressors contribute to impaired functioning. No acute psychiatric safety concerns identified.

P (Plan): Start sertraline 25 mg PO daily for 7 days, then increase to 50 mg daily if tolerated. Discuss medication risks, benefits, and potential side effects. Recommend trauma-focused CBT or EMDR, sleep hygiene, and supportive counseling. Review safety plan and crisis resources. Monitor mood, PTSD symptoms, and medication tolerability. Follow up in 2 weeks.

New Medication: Sertraline 25 mg PO daily × 7 days, then 50 mg daily as tolerated.

Activity Time: 60 minutes
Complexity: Moderate
CPT: 90792
ICD-10-CM: F43.10, F33.1

SOAP 2 :

Demographics: 45-year-old male, divorced, employed part-time, lives with his sister.

Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.

Reason for Visit: Evaluation of mood instability, irritability, impulsive behavior, and worsening depressive symptoms.

Chief Complaint: “My mood is all over the place. Sometimes I feel unstoppable, and then I crash and don't want to do anything.”

Psychiatric Diagnoses:

·        Bipolar I disorder, current episode depressed, moderate (F31.32)

·        Generalized anxiety disorder (F41.1)

Medical Comorbidities: Hypertension, hyperlipidemia, and obstructive sleep apnea.

Current Medications: Amlodipine 5 mg daily, Atorvastatin 20 mg nightly. No current psychiatric medications.

Social Problems: Recent divorce, financial difficulties, unstable employment, strained family relationships, and limited social support.

Procedures: Comprehensive psychiatric evaluation, MSE, mood disorder assessment, mania/depression screening, medication reconciliation, sleep assessment, substance-use screening, and suicide risk assessment.

Clinical Note: Patient reports depressed mood, anhedonia, fatigue, irritability, poor concentration, and decreased motivation for the past two months. Describes previous manic episodes lasting over one week, characterized by decreased need for sleep, excessive energy, pressured speech, grandiosity, and impulsive spending resulting in significant financial consequences. Denies current mania, psychosis, SI, or HI. Reports no recent substance misuse.

S (Subjective): Reports persistent depression, low motivation, excessive worry, disrupted sleep, and difficulty managing daily responsibilities. History of distinct manic episodes with significant functional impairment.

O (Objective): Alert and oriented ×4, casually dressed, cooperative. Mood depressed; affect constricted. Speech normal, thought process linear. No overt psychosis or SI/HI. Insight and judgment fair.

A (Assessment): Bipolar I disorder, current depressive episode, moderate, with comorbid GAD. History of mania and ongoing functional impairment. No acute psychiatric safety concerns identified.

P (Plan): Initiate lurasidone 20 mg PO daily with at least 350 calories of food. Review risks, benefits, and potential adverse effects, including akathisia, EPS, and metabolic changes. Obtain baseline weight, BMI, BP, HbA1c, and lipid panel. Recommend psychotherapy, mood tracking, consistent sleep schedule, and sleep apnea treatment adherence. Monitor mood stability, medication tolerability, and safety. Follow up in 2 weeks.

New Medication: Lurasidone 20 mg PO daily with food.

Activity Time: 60 minutes
Complexity: Moderate
CPT: 90792
ICD-10-CM: F31.32, F41.1

Case Formulation and Treatment Plan Assignment

Purpose: The purpose of this assignment is to complete a comprehensive treatment plan for a specific client (i.e., a client in your clinical practicum, a client in your place of employment, a family member or friend). Assessment, diagnosis, and treatment planning are components of the course and sections to be addressed in this assignment. You cannot use the same case used in another course.

Assignment: The student will be required to provide a DSM-5 TR diagnosis, a treatment plan and a summary integrating evidence-based literature and justifying the treatment plan the student developed for the client. The student will also cross-reference the diagnosis with the DSM 5 TR and note all patient symptoms matching criteria. Submit this assignment to the DROPBOX at the end of Unit 10.

This assignment should be 7 - 8 pages in length, excluding title page and reference pages. Incorporate at least 4 evidenced based research articles that support the diagnosis and treatment planning considerations. Follow the following criteria: