please i need you to be very detail on this one, my professor us very strict
FOLLOW THE RUBRIC!!!!
Step 1: You will use the
to:
- Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
- Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
- For the Comprehensive Evaluation Presentation Assignment: You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).
Step 2: Each student will create a focused SOAP note video presentation in the next assignment. See for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
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S = |
Subjective data: Patients Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
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O = |
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
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A = |
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
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P = |
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
Patient 34 (NEW CONSULT)
Gender: Male
Age: 70
Ethnicity: Hispanic
Race: White
Insurance: Medicare
Reason for Visit: New Consult
Chief Complaint: Ive been feeling nervous and shaky.
HPI:
70-year-old male presents with a 3-month history of excessive worry, restlessness, and muscle tension. He reports poor sleep and constant concern about health and finances. Symptoms occur daily and impair functioning. Denies SI/HI or panic attacks.
Clinical Note:
Anxious, mildly tremulous, cooperative, thought process coherent.
Social Problems Addressed:
Emotional distress, Financial concerns, Health anxiety
Immunizations:
Missing influenza and shingles vaccines
CPT Code: 90792 + 90833
ICD-10 Diagnosis:
F41.1 Generalized Anxiety Disorder
Differential Diagnoses:
- F41.0 Panic Disorder
Supporting: anxiety present but no episodic panic attacks - F45.21 Illness Anxiety Disorder
Supporting: health concerns present but generalized worry predominant - F51.01 Insomnia Disorder
Supporting: sleep disturbance present but secondary
Vitals:
BP: 142/86 | HR: 82 | RR: 16 | Temp: 98.3F | Ht: 58 | Wt: 175 lb | BMI: 26.6
Allergies: Diazepam excessive sedation
Procedures:
GAD-7 (score: 17), MSE, psychosocial assessment
Treatment Plan:
- Buspirone 5 mg PO BID, #60, 2 refills
- Education: delayed onset, adherence
Non-Pharmacological:
CBT to manage excessive worry
Relaxation techniques to reduce physical symptoms
Follow-Up:
4 weeks monitor anxiety symptoms
Keep in mind this is a healthy 70 year old, however add soome medical history like hospitalization for appendicities when he was young and maybe history of hypertension nothing else, dont compolicate it
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