Hi there, I needed help writing an assignment. For a Nursing course of Psychiatr

Hi there, I needed help writing an assignment. For a Nursing course of Psychiatric for nurse practitioners. Masters level. I have to write a SOAP NOTE for a patient I seen, scholarly written, APA formatted, and referenced. A minimum of 4 references are required past 10-years. Please include DIO with references.
K.H
Date of birth, 05/224/2007
Date of service: 10/20/23
16y old female
CC: Cannabis use. Depression level 9/10. Anxiety level 7/10. Increase mood swings and irritability. Incident of self-harm, involving cutting her wrist.
HPI: Haley reported She has been experiencing feelings of sadness following a recent falling out with some of her friends. On a scale of 0 to 10, with 10 representing the most severe, she rates her depression at 9/10 and her anxiety at 7/10. These increased feelings of depression and anxiety are primarily related to the recent conflict with her friends. Haley has perceived a decrease in the effectiveness of her current medications, a sentiment that has also been noted by her psychotherapist. She has noticed an increase in mood swings and irritability but has not displayed aggression toward others or property. Haley disclosed a recent incident of self-harm, involving cutting her wrist with her cosmetic eyelash brush at school approximately two weeks ago. She denied any active suicidal ideation and noted a reduction in the frequency of such thoughts. On occasion, Haley consumes alcohol with friends, typically having 4 to 5 drinks. Additionally, she reported regular use of marijuana and vaping. We discussed the potential risks associated with alcohol use at her age and the potential interactions with her current medications, to which she demonstrated an understanding. Her sleep patterns have remained regular, with her averaging 8 to 9 hours of sleep. There have been no significant changes in her weight, and her appetite remains stable. Haley has maintained adherence to her prescribed medications, and her mother affirmed the accuracy of her reports.
Psychosocial History: Tyshira denies engaging in repetitive or ritualistic behaviors, irritability, mood swings, violent tendencies towards others or property, access to firearms, stealing, or self-injurious behavior. She reports being sexually active and practicing safe sex. There is no history of legal issues, and she is generally respectful and compliant with rules at home and school. However, her academic performance has recently declined, with several F grades, a change from her previous C and B grades. She has also experienced decreased appetite and significant weight loss (from 122 lbs to 108 lbs).
Allergies: NKDA.
Past Psychiatric History: Psychosocial History: Parents divorced. Strain in relationship with parents/primary caregivers. Strain in relationship with parents/primary caregivers. Difficulties with friendships. Current Living Situation/Psychosocial Stressors: Lauren Payne (mother) and Jason Payne (stepfather)
Trauma History: Dad’s temper is bad, but she likes him, does not like her step mom at all, likes her step brother
Personal and Social history: Past Psychiatric History; No psychiatric hospitalization, suicide attempts. Failed trial of Adderall = stopped by MD; Vyvanse=adverse effects. No hx of OCD, PTSD, ASD. Hx of MDD, GAD, ADD, SI, SIB.
Current medications: Clonidine 0.1mg at bedtime; Lexapro 10mg; Abilify 2.5mg
Current diagnosis:
1) F90.2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, COMBINED TYPE
2) F41.1 GENERALIZED ANXIETY DISORDER
3) F33.1 MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE
4) F41.0 PANIC DISORDER [EPISODIC PAROXYSMAL ANXIETY]
Differential Diagnosis:
1) Adjustment disorder with depressed mood.
2) Substance- induced mood disorder
3) Major depressive disorder
Primary Diagnosis: F33.1 MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE
Assessment:
GAD-7= 18
PHQ-9= 21
Denies suicidal or homicidal ideas. Mood anxious, affect is full and appropriate. Appropriate dress, appropriate grooming and hygiene, appears stated age. No acute distress. Modified for telehealth; seated, upright posture, extension of arms. No abnormal movements. Alert and oriented to person, place, time and situation. No abnormal thought content, no auditory or visual hallucinations, no paranoid ideations or delusions. Attention span is intact. Judgment is not impaired.
Plan/ Follow-up:
Medications: Clonidine 0.1mg at bedtime; Lexapro 20mg; Abilify 5mg
If symptoms worsen, recur, or do not improve, consider: Medication adjustment
Adjunct Treatment: Psychotherapy
Lifestyle/Behavioral Modifications: Exercise, increase fluid intake, fall precaution
Patient should return 2 Weeks.

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