Psychiatric SOAP Notes For Clinicals Assignment

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Psychiatric SOAP Notes For Clinicals Assignment

Soap 1:

Chief Complaint: “Nearly every night, I have a nightmare in which I am lost and unable to find my parents.”

S:

HPI: The patient is a 14-year-old Hispanic female accompanied by her father who presents with complaint of frequent nightmares in which she is lost and is unable to find her parents. She claims that she has trouble falling asleep in the dark since she has vivid nightmares at such times. As a result, she sleeps with the lights on. The father reports that the patient also does not like going to school because she does not want to associate with people and prefers to be alone. Her father also brings up the fact that the patient’s teacher often expresses concern with her inability to concentrate in class. The patient also complains of occasional headaches, reduced appetite, and difficulty falling asleep. She also reports constantly thinking about the death of her best friend’s parents who were involved in a car accident two years ago. Psychiatric SOAP Notes For Clinicals Assignment

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O:

Vitals: Temp: 36.9 C BP: 114/77 HR: 93 RR: 13 Ht: 5’0 Wt: 92.5 lbs

ROS: NA

Current medication: None

Mental status exam:

Patient appears well-dressed with fair grooming. She is alert and oriented x4.  Her attention span is limited. Her mood is dull while her affect is flat. She is cooperative, but fails to maintain eye contact. She does not demonstrate any signs of being agitated or restless. There are no abnormalities in her motor function. Her gait is steady, and she maintains an upright posture. A.P has a low pitch in her speech and a difficult time speaking fluently. She had moments when she would demonstrate verbal disorientation by mixing up the words she was saying. Her behavioral and social functions are significantly impaired. She maintains that she would rather be by herself at school and does not want to engage with her other students. Her judgments appear somewhat impaired. Her memory, both short-term and long-term, are intact. She displays a lack of insight into the alterations in her behavior. She denies suicidal ideation, delusions or auditory hallucinations.

A:

DSM5 Principal Dx: Posttraumatic Stress Disorder (PTSD) F43.1

Differential diagnosis

  1. Acute Stress Disorder F43.0

Rational: this condition is often associated with nightmares, excessive worry, and decreased attention.

  1. General Anxiety Disorder (GAD) F41.1

Rational: this condition is often associated with excessive worry and sleep problems. Psychiatric SOAP Notes For Clinicals Assignment

P:

  1. Zoloft 50mg once daily

Rational: Zoloft has been approved as the first-line treatment for PTSD

  1. Laboratory testing: NA
  2. Patient education

– Patient educated on possible side effects of Zoloft

– Patient educated on compliance with the medication regimen

– Patient educated to practice coping strategies that reduce fear and worry

  1. Follow up

Patient to follow up in 4 weeks for progress evaluation

Soap 2

Chief Complaint: “There’s this pain in my neck, it aches, it spreads to my back, I think there’s a lump, right here. I’m really worried.”

S:

HPI: The patient is a 25-year old Caucasian male presenting to the clinic with his colleague who reports that the patient’s productivity at work has been down for three weeks. The client reports pain in his neck that spreads to his back and keeps getting worse. He believes that the pain is due to cancer, caused by “pain, suffering, broken heart” he endures from his colleagues ganging up against him. He denies experiencing any form of abuse. Psychiatric SOAP Notes For Clinicals Assignment

O:

Vitals: T- 98.4 F HR- 80 R- 15 BP- 118/78 Ht- 5’7 Wt- 133 lbs

ROS: NA

Current medication: Levothyroxine for hypothyroidism

Mental status exam:

Patient is occasionally uncooperative with the healthcare provider and declined to answer some of the interview questions. He is well-groomed and dressed properly for the occasion. He exhibits minor motor agitation as he keeps pointing to his neck where the reported pain is located. Appears suspicious of the interviewer and maintains extra vigilant eye contact. His voice is soft at first but becomes louder when he asked about his health problems. Displays flat affect and agitated and irritable mood. His thought process seems non-logical and exhibits greater hesitation in responding to the questions. His thought content comprises paranoid delusions. Has limited concentration span. Memory is intact. He  displays lack of insight into his illness and impaired judgment. Psychiatric SOAP Notes For Clinicals Assignment

A:

DSM5 Principal Dx: Schizophrenia F20.9

Differential diagnosis

  1. Delusional Disorder Persecutory Type F22

Rational: patients with this disorder often exhibit paranoid delusions and irritable mood.

  1. Bipolar Disorder with Psychotic Features F31.2

Rational: Patients with this disorder often experience delusions during depressive episodes.

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P:

  1. Prescribe Clozapine 12.5 mg once  daily

Rational: Clozapine has been found to improve thinking, mood, and behavior

  1. Start cognitive behavior therapy

Rational: CBT has shown efficacy in helping Schizophrenia patients deal with negative feelings.

  1. Patient education

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

– Patient educated on practicing relaxation techniques like meditation and deep breathing

– Patient educated to exercise daily

– Pt educated to seek social support Psychiatric SOAP Notes For Clinicals Assignment

  1. Follow up

Patient to follow up in 2 weeks to evaluate symptoms and medication regimen adherence.

 

Soap 3

Chief Complaint: “My family doctor referred me to you.”

S:

HPI: Patient is a 41-year-old Caucasian female who comes to the clinic after a referral by her family physician. The physician had become worried after she had asked for an Oxycodone prescription. The patient reported that Oxycodone is the only medication that helps with her frequent headaches. She reported that she is opposed to putting anything unhealthy into her body and prefers taking one medication to cater to both of her problems rather than taking more than one drug. She reported that she tried other medications, but nothing else has worked since. She has a history of once trying Tylenol with Codeine, which developed an allergic reaction where her face flushed. She also reported that she had tried using acetaminophen, ibuprofen, codeine, and morphine but they did not work. Reports using alcohol twice per week. Denies history of hallucinations or suicidal or homicidal ideations.

O:

Vitals: T- 97.6 F HR- 83 R- 14 BP- 107/69 Ht- 5’4 Wt- 143 lbs

ROS: NA

Current medication: vitamin supplements

Mental status exam:

Patient is well-dressed appropriately and fairly groomed. She looks anxious, agitated easily, and fidgety. She has a steady gait and is alert and oriented ×4. She has a clear and coherent speech, is in the right tone, and expresses her thoughts and feelings. She appears suspicious during the interview at times; her affect is flat, she has poor eye contact, but she is cooperative. No auditory hallucinations or suicidal/homicidal ideations. Short-and-long-term memory intact. She has a fair judgment and  logical thought process. Insight into her condition is fair. Psychiatric SOAP Notes For Clinicals Assignment

A:

DSM5 Principal Dx: Psychoactive substance abuse F19. 10

Differential diagnosis

  1. Opioid use disorder 90

Rational: Patient reports using Oxycodone for a long time for headaches

Alcohol use disorder

Rational: Patient reports using alcohol twice a week.

 

P:

  1. Prescribe oral methadone 30 mg daily for three days, to be reduced by 20% daily afterwards

Rational: methadone has been approved as a treatment for opioid addiction

  1. Start counseling

Rational: counseling provides necessary support system for the patient

  1. Patient education

– Patient educated on the effects of taking the drugs without prescription

– Patient educated on the being compliant with the treatment prescribed

– Patient educated on the importance of limiting alcohol intake

– Pt educated to join a local support group Psychiatric SOAP Notes For Clinicals Assignment

  1. Follow up

Patient to follow up in 2 weeks

 Soap 4

Chief Complaint: “I haven’t been able to sleep, and I am waking up every hour.”

S:

HPI: Patient is 38-year old African American female who presents with complaints of trouble sleeping for the last four months. She states she does not have trouble falling asleep but wakes often and has trouble remaining asleep. She states that this problem occurs almost every night. The patient states she has tried over the counter melatonin to assist her in falling asleep but it has not helped. The patient states she cannot seem to get into a regular sleep pattern with a consistent rise time. She denies caffeine or alcohol use. States the sleep is affecting her at work.

O:

Vitals: Temp: 98.4 C BP: 120/71 HR: 91 RR: 14 Ht: 5’2 Wt: 133 lbs

ROS: NA

Current medication: None

Mental status exam:

Gait and station: WNL steady walk

Appearance: WNL appropriately dressed

Behavior: anxious

Mood: irritable

Affect: flat

Though process: logical/coherent

Though content: WNL

Perceptual: WNL

Cognition: intact

Attention and concentration: alert and attentive

A:

DSM5 Principal Dx: Insomnia G47.00

Differential diagnosis

  1. Generalized Anxiety Disorder F41.1

Rational: patients with this disorder experience sleep disturbance and irritable mood

  1. Obstructive Sleep Apnea G47.33

Rational: patients with sleep apnea often experience difficulty staying asleep

 

P:

  1. Recommend cognitive behavioral therapy

Rational:  CBT helps maintain good sleep hygiene measures and relaxation techniques.

  1. Patient education

– Patient educated to keep a sleep diary

– Patient educated to avoid caffeine and alcohol especially before bed time

– Pt educated to relax sufficiently before bedtime and create an environment conducive to sleep

– Pt educated to ensure minimal noise level during bedtime

  1. Follow up

Patient to follow up in 2 weeks to evaluate her sleep pattern

Soap 5

Chief Complaint: “I’m so afraid of contaminating the kids’ food once again, and I feel so bad about it.”

S:

HPI: Patient is a 51-year-old Hispanic female who works at a children day care. She complains that ever since a case of food poisoning she caused one year ago at the day care, she has been somewhat depressed and has intrusive thoughts off contaminating the food again. Whenever she starts washing utensils, she takes a lot of time washing her hands and cleaning one utensil after another. She repeats her hand washing every time she thinks it is necessary and avoids shaking hands with anyone. Psychiatric SOAP Notes For Clinicals Assignment

O:

Vitals: Temp: 98.7 F BP: 102/73 HR: 69 RR: 16 Ht: 5’3 Wt: 167 lbs

ROS: NA

Current medication: None

Mental status exam:

Gait and station: WNL steady walk

Appearance: WNL appropriately dressed

Behavior: anxious, guilty

Mood: sad

Affect: flat

Though process: logical/coherent

Though content: intrusive thoughts

Perceptual: WNL

Cognition: intact

Attention and concentration: alert and attentive

A:

DSM5 Principal Dx: Obsessive-Compulsive Disorder F42

Differential diagnosis

  1. Body Dysmorphic Disorder 22

Rational: patients with this disorder being experience excessive concern over physical appearance

  1. Obsessive-compulsive personality disorder F60.5

Rational: Patients with this disorder exhibit extreme perfectionism

P:

  1. Prescribe Clomipramine 25 mg once daily

Rational: Clomipramine helps decrease obsessions and the urge to perform repeated tasks

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  1. Begin CBT

Rational: CBT helps patients develop a more effective way of responding to obsessions and compulsions

  1. Patient education

– Patient educated on being compliant with the treatment regimen

– Patient educated to practice self-relaxation techniques, such as yoga.

  1. Follow up

Patient to follow up in 2 weeks Psychiatric SOAP Notes For Clinicals Assignment