Psychiatric SOAP Notes From Clinicals Assignment Paper
Psychiatric SOAP Notes From Clinicals Assignment Paper
EXAMPLE 1:
Chief Complaint: ” I need to get my medication refilled but also I wanted to talk to you about the xanax that I’m getting. I’m not able to take it like prescribed because I feel like it’s too strong and it makes me feel sedated so I wanted to talk to you about getting that decreased if possible. I do feel like it helps me with my anxiety so I do feel like I need it but I can’t take it as it’s written currently ’cause it’s too strong.”
S:
HPI: Pt is a Caucasian married 30yr old male patient. Came to the office looking to get a refill on his Rx and dose adjustment. He states he’s been doing really good lately and he doesn’t have all of the stressors in his life right now like he had before. He feels like he’s able to interact with his family and he doesn’t have the anxiety attacks and panic to where he’d feel like he had to isolate to the home anymore. Psychiatric SOAP Notes From Clinicals Assignment Paper
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O:
Vitals : Bp 138/70, p 67, R 13 temp 98.1
Anxiety: 0/10 on 0/10 scale
Depression: 0/10 on 0/10
Objective rating scale: becks depression scale : 2
ROS: NA
Current medication:
Buspirone10 mg po bid
Xanax 0.5 mg po q day prn
Mental status exam:
Gait and station: WNL steady walk
Appearance: WNL appropriately dressed
Behavior: calm, cooperative, and pleasant
Mood: Calm
Effect: full range of motion
Though process: logical/coherent
Though content: WNL
Perceptual: WNL
Cognition: WNL
Attention and concentration: alert and attentive
A:
DSM5 Principal Dx: Generalized Anxiety Disorder F41.1
Differential diagnosis
- Panic disorder F 41.0
Rational: patient with generalized anxiety disorders often have panic attacks
- social anxiety disorder F40.10
Rational: social worries are common in patients with generalized anxiety disorder
- Agoraphobia F40.00 Psychiatric SOAP Notes From Clinicals Assignment Paper
Rational: Social disorder related to a fear of public places patient has had increased interaction with the public
Erikson’s psychosocial stages of development: Adulthood (30 to 65 years ) generativity versus stagnation
P:
- Continue Buspirone10 mg po bid. Decrease Xanax 0.25 mg po q day prn # 15 as tolerated and dc.
- Add Vistaril 25 mg po q day prn anxity
Rational: Vistaril show to be effective in the treatment of generalized anxiety disorder
- Laboratory testing: NA
- Patient education
– Patient educated on possible side effects buspironeand Xanax in order for patient inform and can address side effects.
– Patient educated on taking medications as prescribed and avoid missing doses To maximize efficiency of medication .
– Patient educated to report any increased depression or anxiety, so you can maximize the efficiency of the treatment plan and adjust as needed
– Pt also educated on GCAL # 8007154225, to provide emergent contact in the case of crisis
– Continued therapy 1 on 1 is recommended, to improve success of treatment plan.
5.follow up
Patient follows up in two weeks for evaluation of medication change. Pt was also educated to get back in sooner if needed for sooner follow up visit.
EXAMPLE 2:
Chief Complaint: “” I feel like everything around me is just collapsing. I feel like if I’m just progressively getting worse and I really don’t understand why I’m taking the medication that I’m prescribed but it just feels as if nothing is helping me and nothing is working.”
S:
Pt is a 14 yr old caucasion female seen in the office with her mother for a follow up visit. The pt mother agrees with the following reported by the patient. Patient states she just really wants help and get better. She states she finds herself isolating in her room and she doesn’t want to be around others not even family. He says she still talk to friends sometimes on her cell phone but her mom has been living with her as well so that’s a stressor too.
O:
Vitals : Bp 112/85, p 75, R 12, temp 97.1
Anxiety: 0/10 on 0/10 scale
Depression : 5/10 on 0/10
Objective rating scale: becks depression scale : 15
ROS: NA
Current medication
Prozac 10 mg po q d mg po q day
Mental status exam
Mental status exam: not done due to age.
Gait and station: WNL steady walk
Appearance: clean neat and dressed appropriately
Behavior: calm, cooperative, and pleasant
Mood: Calm but depressed
Effect: full range of motion
Though process: logical/coherent
Though content:WNL
Perceptual: WNL
Cognition: WNL
Attention and concentration: alert and attentive
A:
DSM5 Dx
Major depressive disorder F 33.1
Differential diagnosis
- Mood disorder due to another medical condition /F06.30
Rational: conditions such as hypothyroidism cause depression
- Mood disorder due to another medical condition /F06.30
Rational: conditions such as hypothyroidism cause depression
- Adjustment disorder with depressive mood/ F43.21
Rational: depression can be the result of psychosocial stressors
Erikson’s psychosocial stages of development: school age (6 to 12 years) Industry versus inferiority
P:
Increase Prozac 20 mg po q d depression
Rational: the increase in the dose can be effective in decreasing the patients depression.
- Add Lexapro 10mg po q d anxiety depression
Rational: SSRI anti depressant
- Laboratory testing
NA
- Patient education
. – Patient educated on possible side effects of prozac in order for patient inform and can address side effects.
– Patient educated on taking medications as prescribed and avoid missing doses To maximize efficiency of medication .
– Patient educated to report any increased depression or anxiety, so you can maximize the efficiency of the treatment plan and adjust as needed
– Pt also educated on GCAL # 8007154225, to provide emergent contact in the case of crisis
– Continued therapy 1 on 1 is recommended, to improve success of treatment plan.
5.follow up
Patient follows up in two weeks for evaluation of medication change. Pt was also educated to get back in sooner if needed for sooner follow up visit.
Example 3
Subjective:
CC: “I am concerned about my mental health.”
Andrea is a 23-year-old female who presents to the clinic concerned about her mental health. She states she was not honest on her initial psychiatric evaluation for fear of needing to be institutionalized. Patient states she has been experiencing what she believes to be manic episodes since she was a child, which have changed in frequency and intensity as an adult. She states her mood shifts daily but it gets worse a few days before her menstrual cycle where she will have a manic episode lasting 2-3 days. She notes she has extreme energy and irritability, goes a day or two without sleep, has an increased sex drive, and has sporadic spending sprees of thousands of dollars in a short amount of time during the episode. Patient states she becomes extremely depressed following the manic episode. Patient states she was baker acted on 5/19/22, after having an intentional overdose. She states during a manic phase she posted something on social media regarding a start-up business, and when it did did not get the response she anticipated, it triggered an episode of severe depression causing her to take a bottle of fluoxetine capsules. She called her sister who called the sheriff, and was taken to the hospital, where she was monitored and stabilized for 3 days. Patient was not given a diagnosis at the hospital, was discharged on her current medication regimen and asked to follow-up with a psychiatrist. Patient is currently being treated for depression and anxiety disorder on a medication trial of fluoxetine 40 mg once a day (QD). She states she stopped taking fluoxetine prior to her overdose because it was causing her to have increased anxiety and manic episodes, as well as giving her a mental “fog” where she could not even form sentences. Patient denies smoking, alcohol, or use of drugs. Patient notes her sleep, appetite, and weight are currently stable.
Objective MSE:
This visit is conducted via teleheath. The patient appears her stated age, has good eye contact, and is cooperative and pleasant with no apparent distress. She is wearing appropriate attire and has adequate hygiene and grooming. Her speech is regular in rate and volume. She relates depressed mood. Affect is congruent. Her thought process is linear and goal directed and her association is logical. Patient denies delusions, hallucinations, suicidal or homicidal ideation, ruminations or obsessions. Patient’s attention, concentration, memory, language, and fund of knowledge is within normal limits and adequate per conversation. Her insight and judgment are fair.
Assessment:
Problem #1: Mood (Affective) Disorder (F39.0). Mood (Affective) Disorder versus Bipolar Disorder. Will continue to monitor to determine if Mood (Affective) Disorder or Bipolar Disorder; Problem #2: Major Depressive Disorder, recurrent severe without psychosis (F33.2). Patient with ongoing symptoms. Will continue with close follow-up; Problem #3: Generalized Anxiety Disorder (F41.1). Patient with ongoing symptoms. Will continue with close follow-up; Problem #4: Poisoning by unspecified drugs, intentional self-harm (T50.902A).
Current Medications:
Fluoxetine 40 mg, one capsule po q day
Plan:
Discontinue fluoxetine 40 mg once a day.
Start lamotrigine 25 mg once a day. Patient will be informed to discontinue lamotrigine if she develops a rash.
Start aripripazole 5 mg once a day.
Continue with Cognitive Behavioral Therapy weekly.
Follow-up appointment in two weeks for medication dose titration.
Patient verbalizes understanding of her treatment plan and knows to call the clinic sooner with questions or concerns. Psychiatric SOAP Notes From Clinicals Assignment Paper
