Psychiatric SOAP Notes From Clinicals Assignment

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Psychiatric SOAP Notes From Clinicals Assignment

Soap 1:

Chief Complaint: “I feel sad and low at all times.”

S:

HPI: The patient is a 48-year old Caucasian female who has reported that she began experiencing symptoms of sadness around five months ago.  She reports that she no longer has interest in almost all activities that she used to love. She states that in the past she has taken 30 milligrams of Paxil every day in order to keep her moods under control. Aside from the medicine, the only thing that helps her feel better is listening to music and sometimes going on walks around the river. She has also made an attempt at ending her own life since she believes no one in her family cares about her. Psychiatric SOAP Notes From Clinicals Assignment

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O:

Vitals: Temp: 37.5 C BP: 126/88 HR: 82 RR: 15 Ht: 5’4 Wt: 171 lbs BMI: 29

ROS: NA

Current medication: Paxil 30 mg once daily

Mental status exam:

Gait and station: WNL steady walk

Appearance: WNL appropriately dressed

Behavior: distressed

Mood: sad

Effect: full range of motion

Though process: logical/coherent

Though content: WNL

Perceptual: WNL

Cognition: intact

Attention and concentration: alert and attentive

A:

DSM5 Principal Dx: Major depressive disorder F33.1

Differential diagnosis

  1. Anxiety Disorder F41.9

Rational: patient with anxiety disorders often experience low mood.

  1. Persistent depressive disorder 1

Rational: patients with this condition often present with loss of interest in normal activities and low mad Psychiatric SOAP Notes From Clinicals Assignment

P:

  1. Discontinue Paxil 30mg/day
  2. Prescribe Lexapro 20mg/day

Rational: Lexapro has a more tolerable side effect profile in treating depression

  1. Laboratory testing: NA
  2. Patient education

– Patient educated on possible side effects of Lexapro

– Patient educated on taking medications as prescribed

– Patient educated to prioritize sleep to deal with low mood

– Pt educated to do light exercises at least three days per week

5.follow up

Patient to follow up in 4 weeks to evaluate symptoms.

 

Soap 2

Chief Complaint: “I have been getting nightmares and I am also excessively anxious.”

S:

HPI: The patient is a 31-year-old Hispanic male who was brought by the authorities after he attempted to commit suicide by falling from a footbridge. He said that he had been in Iraq for three deployments, the most recent of which was three months ago, but that he was the sole survivor of an ambush that occurred while their convoy was traveling. He had been released from the marine unit two months earlier. Since that time, he has been beating himself up over what transpired and is certain that he had the ability to prevent it and rescue them. On the other hand, he does not like discussing the particulars of that episode, and he claims that he is not prepared to speak to anybody under any circumstances. He has also been having trouble sleeping, and when he does fall asleep, he has been experiencing dreams. He adds that this has been happening often recently. According to him, he had a recurring dream in which he saw the place where they had been ambushed together with the dead corpses of his fellow soldiers. He claims that, as a result of his highly aggressive and irritated nature, he has been getting into fights more often than usual. Psychiatric SOAP Notes From Clinicals Assignment

O:

Vitals: Temp: 37.2 C BP: 122/79 RR: 17 HR: 88 Ht: 5’8 Wt: 185 lbs

ROS: NA

Current medication: None

Mental status exam:

Patient appears appropriately dressed, well-groomed. He struggles to maintain eye contact, he is calm and composed when answering questions, he has poor concentration, but he was cooperative. His speech is comprehensible, and it is in the normal rhythm, rate, volume and the variation in tone is also normal, and his mood is self-reported to be guilt and his affect is blunted. He was noted to have a decreased rage of positive emotions, he had amnesia for some parts of the traumatic event, he has suicidal behaviours. He has a goal-oriented thought process, he appears paranoid and has a sense of self-blame, and he is aware of his problem and is willing to get help. Psychiatric SOAP Notes From Clinicals Assignment

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A:

DSM5 Principal Dx: Post-traumatic stress disorder F43.1

Differential diagnosis

  1. Acute stress disorder F43. 0

Rational: patients with PTSD often experience sleep disturbances and nightmares.

  1. Major depressive disorder F33.1

Rational: Patients with depression often experience suicide ideation.

  1. Anxiety disorder 9

Rational: Patients with anxiety disorder often get repeated flashbacks of traumatic experiences Psychiatric SOAP Notes From Clinicals Assignment

 

P:

  1. Prescribe Sertraline 25 mg daily orally, Prazosin 1 mg orally at bedtime

Rational: Sertraline and Prazosin have been found to improve PTSD symptoms and overall functioning.

  1. Start trauma-focused cognitive behavioural therapy

Rational: trauma-focused cognitive behavioural therapy improves coping techniques so that a person can better react to reminders of the traumatic experience and the emotions connected with it.

  1. Patient education

– Patient educated on importance of being compliant with the medication regimen

– Patient educated to practice self-calming techniques

– Patient educated to find a support group near his home and join one

– Pt educated on the importance of attending all the follow-up visits

5.follow up Psychiatric SOAP Notes From Clinicals Assignment

Patient to follow up in 4 weeks to evaluate symptoms.

 

Soap 3

Chief Complaint: “I was sent here to come and see you.”

S:

HPI: Patient is a 17-year old African American female with a history of type 1 bipolar disorder presents to the clinic accompanied by her uncle. She reports that she had spent the previous years in the care of a foster family, but that she had only just moved in with her aunt two months ago. The uncle said that she had some concerns about her niece’s conduct. Patient reports that she wanted to be able to live at her friend’s place whenever she pleased, but her aunt did not agree with her decision. She also admitted that she had been indulging in risky habits, such as smoking marijuana and having sexual relations with a number of different people, some of whom were complete strangers. She said that there are occasions when she has the urge to cut her hand in order to inflict damage on herself. She also reports sleeping difficulties and hearing voices.

O:

Vitals: Temp: 36.7 C BP: 122/79 HR: 74 RR: 16 Ht: 5’8 Wt: 185 lbs

ROS: NA

Current medication: Topamax and Vistaril,

Mental status exam:

She is an African American female patient with a normal gait; she is in a good nutritional status, has a normal gait, is dressed suitably for the current weather, and is groomed well. She appears indifferent, is cooperative during the assessment, maintains eye contact, and has good communication skills. She is awake, alert, and oriented ×4, her speech is coherent and is in the right in tone and volume; she is anxious labile, her thought process is logical and well organized. She does not have evidence of suicide or homicide ideations, visual/auditory hallucination, or a normal thought process. She has an intact short-term and long-term memory and has little insight into her illness Psychiatric SOAP Notes From Clinicals Assignment

A:

DSM5 Principal Dx: Bipolar disorder type 1 F31. 1

Differential diagnosis

  1. Schizophrenia F20. 9

Rational: patients with Schizophrenia often report sleep problems and hearing voices.

  1. Major depressive disorder F33.1

Rational: Patients with depression often experience feelings of self-harm.

  1. Schizoaffective disorder 9
  2. Rational: Patients with Schizoaffective disorder often engage in risky behaviors

 

P:

  1. Continue Topamax and Vistaril

Rational: The patient reports that these medications have been effective

  1. Start cognitive behavioral therapy

Rational: CBT will help the patient develop coping skills

  1. Patient education

– Patient educated on the importance of being compliant with the medications prescribed

– Patient educated on the importance of being physically active

– Patient educated on the importance of abstaining from marijuana, alcohol and risky behaviors

– Pt educated to join local support groups and attends all therapy appointments

5.follow up

Patient to follow up in 2 weeks

 

Soap 4

Chief Complaint: “my mother called the police on me since she wanted me to go back to my boyfriend.”

S:

HPI: Patient is a 27-year old Caucasian female who exhibits symptoms of a mood disorder. She decided to quit taking the drugs prescribed to her since they do not help her feel better. In addition to this, she is an avid drug user who has a history of both overdose and attempted suicide in the past. Because of her actions, her mother had no choice but to call the authorities on her daughter. Following the examination, it was suggested that she see a psychiatrist for further treatment. She grouses about how she can’t sleep at night because she keeps hearing voices in her head. In a similar vein, her pattern of sleep shifts all over the place depending on how she’s feeling. Psychiatric SOAP Notes From Clinicals Assignment

O:

Vitals: Temp: 36.8 C BP: 122/74 HR: 78 RR” 15 Ht: 5’6 Wt: 1156 lbs

ROS: NA

Current medication: Zoloft, Seroquel, and Risperidone

Mental status exam:

Gait and station: WNL steady walk

Appearance: WNL appropriately dressed

Behavior: distressed

Mood: sad

Effect: full range of motion

Though process: logical/coherent

Though content: WNL

Perceptual: WNL

Cognition: intact

Attention and concentration: alert and attentive

A:

DSM5 Principal Dx: Major depressive disorder F33.1

Differential diagnosis

  1. Anxiety Disorder F41.9

Rational: patient with anxiety disorders often experience sad mood.

  1. Historic personality disorder 4

Rational: The patient’s condition might have been inherited from her parents

 

P:

  1. Refer to counseling at least twice a week
  2. Provide various resources and emergency numbers.
  3. Laboratory testing: NA
  4. Patient education

– Patient educated to prioritize sleep to deal with low mood

– Pt educated to do light exercises at least three days per week

5.follow up

Patient to follow up in 2 weeks

Soap 5

Chief Complaint: “I need to get sober and stop doing crack I think I’m going to die soon if I don’t.”

S:

HPI: Pt is a 32-year old Caucasian male who reports he began to use cocaine recreationally at age 18 while he was in college but realized it became an issue when he now uses crack cocaine over the past 1 year. He is unable to quantify how much he smokes but spends “a couple hundred dollars” per day on crack. He reports date of last use was 6/24/2022. He has also been smoking 1 PPD cigarettes since the age of 13. He reports depressive episodes, he reports depression for most of the day nearly every day. He reports that he has felt like this for months. When severe he cannot get out of bed and finds that he has poor hygiene, anhedonia, feelings of worthlessness, anxiety, hypersomnia, and decreased energy Psychiatric SOAP Notes From Clinicals Assignment

O:

Vitals: Temp: 37.1 C BP: 113/76 HR: 82 RR: 16 Ht: 5’6 Wt: 158 lbs

ROS: NA

Current medication: None

Mental status exam:

Patient has disheveled dressing and is groomed fairly. He looks sad, anxious, agitated easily, and fidgety, but he has a steady gait and is alert and oriented ×4. He has a clear and coherent speech, is in the right tone, and expresses his thoughts and feelings. He appears suspicious during the interview at times; his affect is flat, he has poor eye contact, but he is cooperative. He denies hallucinations ideations of suicidal/homicidal, and his short-and-long-term memory is remarkable. He  has a fair judgment and has a logical thought process, and the insight of his condition is fair.

A:

DSM5 Principal Dx: Cocaine use disorder, severe F14.20

Differential diagnosis

  1. Major depressive disorder F33.1

Rational: patient reports depressed mood and feelings of worthlessness

  1. Drug induced mood disorder

Rational: Patients with cocaine use disorder may develop depressive symptoms.

P:

  1. Prescribe fluoxetine 20mg PO QAM

Rational: fluoxetine has less side effects

  1. Begin CBT, group therapies and individual therapy sessions

Rational: these therapy techniques will help the patient stay clean and cope with life

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  1. Patient education

– Patient educated on on the effects of taking the drugs

– Patient educated on being compliant with the treatment provided, including the therapy sessions,

– Patient educated to join a support group go to a rehabilitation center

  1. Follow up

Patient to follow up in 2 weeks

Need 5/30 psychiatric SOAP notes so I can log them into InPlace. This is an online platform where psych nurse practitioner students log in clinical hours and their SOAP notes for clinical experiences.
Please let me know if you have any questions. Thanks! Psychiatric SOAP Notes From Clinicals Assignment