PRAC 6665 Week 7 Assignment 2; Focused SOAP Note and Patient Case Presentation (March 2022)

HPI: The client is a 59-year-old female who presenting for an initial psychiatric evaluation. Client’s daughter was intermittently present for interview (ROI in file). Per chart review/records, client was admitted to mental health hospital for suicide attempt; walking into traffic. Client was discharged with a diagnosis of major depressive disorder, anxiety, insomnia, and post-traumatic stress disorder (PTSD). Today, client presents appropriately dressed, speech clear. However, client presents with child-like affect and is seemingly a poor historian. Client began experiencing auditory hallucination during session, placed both hands over her ears, became tearful and yelled, “ please stop, please stop.” Client’s daughter had to be summoned to the room to provide comfort. Client answered assessment questions but at times, became tearful and at other times could not provide meaningful answers to inquiries. Client could not discuss family history in detail, nor could she provide PMH diagnoses, dates of diagnoses, treatments and could not tell writer if she graduated from high school...