1. Please write three Objectives of the SOAP NOTE
2. Three differential diagnoses for schizophrenia
4. Case Formulation and Treatment Plan
5. Three questions for classmate
Patient history Pt is 40 Y old female was seen today with family member for schizophrenia and unspecified mood disorder with hearing impairment. Pt has hard hearing but can read lips. Pt appeared to be very paranoid. She said she has stopped taking her medication from the last visit stating that she does not need any medication. Her family member who has been taking care of her since her mother passed away admits it has been difficult working with her. Family member reports that she refuses to work and has not been able to pay her bills.
I will attach sample with this. Please do just five main points that I listed above. The sample doesn’t have differential diagnoses and reflection, but you will do it on this assignment. You have done similar assignment before. Don’t forget references.
Objectives of the SOAP NOTE
1. Be able to remember that the diagnosis of DMDD emerges during childhood or adolescence and no diagnosis can be made before the age of 6 or after the age of 18.
2. Understand and differentiate between ODD, DMDD, and Intermittent explosive disorder
3. Remember that the diagnosis of DMDD does not necessarily mean the diagnosis of bipolar later on.
Case Formulation and Treatment Plan:
The client is an 11-year-old Caucasian female who comes in due to anger, irritability, outbursts of yelling, screaming, argumentative and destructive behaviors. Getting tearful is also reported, meltdowns occurring during the night or when unable to answer questions at school were reported. These behaviors have been reported to have occurred for over 12 months. The patient has a diagnosis of GAD and ADHD and takes clonidine 0.1 mg daily and has been taking the medications for about 4 months. The patient is to begin Abilify 2 mg daily and to follow up with the NP in about 4 weeks. Stahl (2017) explains Aripiprazole is a dopamine partial agonist and a mood stabilizer. The patient and the foster mother also received education regarding the medications and to call NP if any issues arise. The patient is also to continue with behavioral therapy to allow her to control her emotions while also attempting to avoid angry outbursts. Wheeler (2014) emphasizes that both psychotherapy and pharmacological interventions are beneficial to clients with DMDD. CBT can be used to teach the client to effectively change their thoughts and emotions ultimately changing their behavior per Wheeler (2014). Sadock, Sadock & Ruiz (2014) state that if a parent has a diagnosis of having a mood disorder, the probability of their offspring having a mood disorder diagnosis will likely be about 10 and 25%.
Children who have a diagnosis of DMDD do not have mania as explained by Mulraney et al. (2021) but have comorbidities to ADHD, OCD, and CD. Parent training is part of the first-line treatment in the care of clients with DMDD according to Mulraney et al. (2021). The Antecedent Behavior, Consequence model is used to inspire parents to comprehend triggers, mannerisms, and act when the behaviors are experienced per Mulraney et al. (2021). Sauer and Gill (2020) report using Equine therapy as part of the treatment found in an Adlerian theory.
One health promoting intervention is not drinking soda which she reported she drinks and a balanced diet was encouraged. Encouraged to participate in her hobbies which included swimming, riding horses. Patient education was to refrain from blue lights 2 hours before going to bed and only using the bedroom to sleep and nothing else. The patient was seen this week and therefore this writer has not been able to follow up. I would have allowed a longer time for contact with the patient and her foster mother.
1. What other medications can be tried on the client
2. What other types of therapy can be used
3. Any patient education can be included.