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Asked by DrMoonRook8
Come up with patient logs for individual psychotherapy, this is a very short note that summarizes a soap note. examples will be provided below, no reference or in-text citation needed. just a short note for psychiatric diagnosis.Â
Example 1
A 39 year old American female presented with complaints of difficulty in sleeping, sadness, fatigue, and loneliness. Patient had a history of 3 failed relationships and is paranoid that she will never get married, have a family, and carry her own baby. Patient had history of hospitalization due to her suicide attempt. She states that she is taking her antidepressants on a daily basis. The session focused on proper management of emotions and dreams, and exploration of the future possibilities. Initial diagnosis: Anxiety disorder. Tx plan: Continue psychotherapy and medication therapy.
Example 2
A 29 year old Latin man characterized to have low-esteem, avoidance of full range of emotions, and extreme sensitivity. The patient and his brother had a history of car accident 3 months ago which resulted to his brother’s death. He takes blame for it and showed excessive guilt since then. The patient is thin since he his anxiety affected his eating routine. Since then, the patient became uneasy, too cautious, and overly organized and clean. Diagnosis: Guilt, depression, and Obsessive Compulsive Disorder (OCD). Treatment plan: pyschotherapy sessions twice a week, and antidepressants.
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