Question Answered step-by-step A very depressed 36-year-old African American woman named Mindy is… A very depressed 36-year-old African American woman named Mindy is referred to outpatient therapy five months after giving birth to her third child. She states she has two boys and the newest is a girl. She talks with a flat affect when describing her lack of interest in being a mother. She also expresses concern over recurring thoughts of seeing herself drop her baby, and cries as she discusses it, stating, “I would never hurt my baby. Why do I keep having images of dropping her down the stairs or in the bathtub? It is so distressing.” It has been difficult for her to get out of bed in the morning, and showering/hygiene has been poor. She presents to the appointment wearing leggings, an oversized shirt, very messy hair, and house slippers. She reports her husband is upset because he wants things to get back to “normal.” She also expresses fear of letting others hold the baby, as she has similar images of dropping the baby during transfer to the other person.She reports no complications during pregnancy or delivery, but states she was much more emotional this pregnancy but is unsure why. She reports she is breastfeeding and that this is the only piece of motherhood she feels she is coping well with. She cries more as she discusses missing her life before the third baby, and how her other two children were such good babies. She states, “This one . . . she just never sleeps. I can’t get any rest. I am so tired.” She struggles a great deal to transition to taking care of three children versus two and expresses she is a failure and things are never going to be “normal” again. She has decided not to return to her job as a financial advisor and, instead, has decided to stay home full time.Her husband does accompany her to the clinic, but she reports to the session alone, leaving him and the baby in the waiting room.Vitals: 136/78, 98.2, 20, 74, 99%, 5’9″, 178 lbsQuestions:Follow-up Session SOAP NoteAccompanied by: CC: HPI: S- Crisis Issues: Reviewed Allergies: NKACurrent Medications: ROS: O-Vitals:PE: (not always required and performed, especially in psychotherapy only visits)Heart- Lungs- Skin- Labs: Results of any Psychiatric Clinical Tests: MSE:A – with (ICD-10 code)Differential Diagnoses:1. choose 3 differential diagnoses (give rationale for diagnoses to support DSM5 criteria)2.3.Definitive Diagnosis:P-Pharm: Non/Pharm: Psychotherapy Modality used: Interventions/Homework: Educations: Safety Plan: Follow-up: Referrals: Reference: Corey, G. (2016).? Theory and practice of counseling and psychotherapy (10th ed.). Cengage. Health Science Science Nursing NU 646 Share QuestionEmailCopy link Comments (0)