psych soap note, template and rubric attached.
template attached
Patient name, GR- will fill in remaining name and vitals at end, other stuff will need to develop
HPI: Patient is a 14 year old male patient who presents with mother for follow-up on depression and ADHD- predominately inattentive type. GR is a 14 year old male who presents with his mother for a follow up visit for the management of depression, social anxiety, and binge eating disorder. He takes Vraylar and Venlafaxine ER 150mg. During last visit, we started Vyvanse 20mg due to
poor focus, inattentiveness, and to assist in the binge eating disorder (BED). He reports feeling some improvement. He feels more energy and is not sleeping all day like he used to. He also relates to decreased appetite and denies episodes of binge eating.Gavin still reports sleeping 12 hours at night. He does not take as many naps as he used to. Patient does online school from home. He relates to improved motivation. Gavin reports moderate depressive and anxiety symptoms. PHQ-9 score is 12. GAD-7 score is 14. His mother reports noticing improved mood. He has been going out more and willing to dine at restaurants. We’ll continue Venlafaxine ER 150mg daily. Increase to Vyvanse 30mg daily in the morning. Follow up in three weeks.
Chief Complaint, patient “I am feeling more motivated and interested in leaving the house.” Mother, states “I see some improvement and he is socializing more with the family at home.”
Medications are: Lisdexamfetamine (Vyvanse) 30 mg capsule, take one tablet every morning, Venlafaxine ER 150 mg capsule ER, take one capsule in the morning, every day
Primary Diagnosis, Depression, moderate, recurrent. ADHD-predominately inattentive type, and Binge Eating disorder (BED). Plus in ICD 10 codes
Differentials: Anxiety, Social anxiety, thyroid abnormality, anemia- iron versus folate/ b12 (micro versus macrocytic anemia)
Follow-up in 3 weeks
Continue current prescriptions x 30 days
Will need at least three references, APA- in past five years- in text citations for differentials and main diagnosis