- A 32-year-old white female is in the office today with a chief complaint â€œI have to force myself to go to work and other than that I donâ€™t want to leave my house.â€
- 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
Construct your response as an abbreviated SOAP note (SubjectiveObjectiveAssessmentPlan).
Structure your â€˜Pâ€™ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the â€˜headingâ€™ and after the â€˜:â€™ input N/A]
Therapeutics:pharmacologic interventions, if any â€“ 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 â€˜therapeuticsâ€™ 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 â€˜Advanced Care Planningâ€™ with the patient/patientâ€™s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate â€“ 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 â€˜Pâ€™ with scholarly resources.