A 32-year-old white female is in the office today with a chief complaint “I have to force myself to go to work and other than that I don’t want to leave my house.”
She reports that last week she tried to go to a Pampered Chef party one of her coworkers was having and she only got about three blocks from her house and had to turn around and go back home.
She admits that being anxious is not new for her but feels as though lately those feelings are negatively impacting her life.
Her medical history is inclusive for a diagnosis of psoriasis.
She is married and has a 4-year-old son.
She is presently on no routine medications. She takes an over-the-counter B-50 vitamin to help her manage stress associated with marital strife and childcare challenges secondary to her work schedule.
Her last menstrual period was two weeks ago.
BP 100/58, P 66, R 18
Large raised silvery-white scaly patch noted posterior occipital region of scalp; no thyroid enlargement or tenderness with palpation; heart -regular rate and rhythm; lungs are clear to auscultation
Utilize the information provided in the scenario to create your discussion post.
Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).
Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]
Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
Educational: health information clients need to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
Support the interventions outlined in your ‘P’ with scholarly resources.
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