Order from us for quality, customized work in due time of your choice.
SOAP note based on below information and please look at rubric for required information:
Andrea
2/19/1987
37 year old Hispanic female, single with two children
Was in foster care and was in 10 different homes as a youth
Lives in San Antonio TX
She took Buspirone and trazodone for 2 years
Cc: prior provider not in network and she is out of medication and when she doesn’t have the medication she has alot of anxiety and it’s not good. Been out since Sunday
Previous medications:
Buspirone 15 mg bid
Trazodone 50 mg
Psychiatric Dx: anxiety, depression, insomnia. Younger was diagnosed with ODD
Medical History: ODD as a child, denies any other medical history
In therapy currently
Single mom
Weight: 245 lbs
Height: 5ft 2 inches
Took Depakote as a child
Trauma: sexual, emotional, physical as a child
Education: Graduated highschool, Some college
Religion: Spiritual but not in church, catholic
No suicide
Drink occasionally
Heroin use in the past, took Methadone for 3 years, 75 mg
Symptoms: Has periods of elevated mood: spends money, engages in risky sexual activity. Has periods of depression as well.
No caffeine use
Plan: Will start Lamotrigine 25 XR and contine therapy
Children 8 and 12 years old
Occupation: Works for high security job
If rash discontinue Lamotrigine due to Stevens Johnson syndrome
New Diagnosis: Bipolar Type 1
Will follow up in 2 weeks.
Order from us for quality, customized work in due time of your choice.