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Please write a Problem-Focused SOAP NOTE and a reflexion based on the information below. Also attached are the instructions and a sample of a Problem-Focused Note.
Ms. Coralee is a 28-year-old female of Puerto Rico descent, single but engaged, mother of none, who presented to clinic to establish care and reports historical diagnoses of Major Depressive Disorder, Generalized Anxiety disorder and ADHD. She reports getting off all her medications about a year ago due to lack of insurance and is presently down and depressed as well as anxious and irritable nearly every day. She is also easily distracted, feels abandoned and empty, guilty and worthless as well as troubles initiating sleep and staying focused and on tasks nearly every day. Her records show previous differential diagnosis of Bipolar Disorder and that diagnosis is supported by the MDQ screening. She has a bachelor’s degree in global studies, policy & economy, and works full-time with Americorps. She lives with a roommate but does not feel safe in the neighborhood.
She reports having Diabetes Mellitus and PCOS and thinks she “might have Hypertension; experiences GERD/Heartburn when she has “too much gluten, and reports gaining about 5 pounds in the last few weeks. She is hard of hearing and thinks she needs her wisdom teeth extracted, wears glasses for sight, and has a history of broken left leg as a child as well as a fractured should, hip pain exacerbated by her weight. Denies any history of asthma or of seizures or concussions. Denies any active legal concerns.
Ms. Coralee is the second of 3 children by her father and the 3rd of 4 children by her mother, from an intact family. Reports her father “has anger issues” and might have major depression and ADHD but is unaware of her mother’s medical or mental health history. “She might be bipolar and once had hallucinations, but ‘Jesus saved’ her…” two of her siblings suffer from mood disorders, borderline personalities, and PTSD; her brother additional suffers from ADHD and alcoholism. She reports a history of extensive abuse and trauma including physical and emotional abuse by parents who she said “ruled by fear… physically assaulted me until I was 10 years old when my mom hit my head on the kitchen counter…” She reports that when the physical abuse stopped, the emotional abuse got worse. “They threatened violence often… Mom put me down daily… She said things like I was ‘ugly, unlovable’ and that my family didn’t love me… also that I would die alone…” Stated that her mother would often call her fat and told her that she ‘should have had an abortion…” instead of having her. “She threw a party when my sister graduated from high school, but did not do one for me…” Ms. Coralee also reports a history of sexual abuse but would not elaborate further today.
Ms. Coralee reports a history of 3 inpatient admissions for psychiatric reasons, last one in 2019, 3 “half-assed” suicide attempts by cutting, last one in 2020; also has a history of other self-injurious behaviors like cutting. She denies a history of significant use of illicit substances other than cannabis, denies any past treatments for alcohol or chemical dependency. Presently states she no longer smokes tobacco or vapes nicotine products and drinks alcohol rarely. She denies any thoughts, intent, or plan to harm self or others
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