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Psychiatric SOAP Note Template
Encounter date: _______18/03/2023_________________
Patient Initials: __S.S.____ Gender: M/F/Transgender __Male__ Age: ___25 years__ Race: __Caucasian___ Ethnicity ___white_
Reason for Seeking Health Care: “I am feeling very paranoid and anxious all the time. I can’t trust anyone and feel like there are people watching me outside my window and I can hear them plotting how they are going to kidnap me. They are making me feel scared and confused.”
HPI: The patient who is a 25-year-old man who is brought to the clinic by his concerned girlfriend. The girlfriend admitted that she is worried about the patient as he has been acting paranoid and locks himself in his house most of the day for 4 days now claiming bad men are out to get him. The patient admitted that even though nobody else can see them he can and he knows they have been sent to get him because he can hear them. He also claims he can see their shadows and that is why he knows they are three men dressed in black and are wearing masks to cover their faces. The patient admitted to first seeing them 4 days ago and they initially just watched him from his bedroom window. He then claimed 2 days ago he began to hear them talk about kidnapping him. The patient admitted that he has not been able to sleep properly for fear of them getting him when he is asleep. He admitted to drinking 4 beers a day and smoking a pack of cigarettes each day. The patient admitted that he lost his father in a car crash 1 month ago. The patient denied currently taking any prescription or over-the-counter medications. The patient denied suicidal or homicidal ideations, weight loss, or changes in appetite.
SI/HI: The patient denied having any thoughts of suicide or harming others.
Sleep: The patient admitted that he has been having trouble sleeping for fear of being kidnapped in his sleep.
Appetite: The patient denied a loss of appetite or an increase in appetite
Allergies(Drug/Food/Latex/Environmental/Herbal): The patient admitted to being lactose intolerant which causes him to experience diarrhea and bloating.
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
| Date | Hospital | Diagnoses | Length of Stay |
| None
|
None | None | None |
| None | None | None | None |
Outpatient psychiatric treatment:
| Date | Hospital | Diagnoses | Length of Stay |
| None | None | None | None |
| None | None | None | None |
Detox/Inpatient substance treatment:
| Date | Hospital | Diagnoses | Length of Stay |
| None | None | None | None |
| None | None | None | None |
History of suicide attempts and/or self-injurious behaviors: The patient admitted to having a history of cutting his arms with a razor blade when he was 19.
Past Medical History
- Major/Chronic Illnesses: The patient denied being diagnosed with any major or chronic illness.
- Trauma/Injury: The patient admitted that 3 days ago he fell off his bike when trying to outrun the shadows of the bad men following him.
- Hospitalizations: The patient denied having a history of hospitalizations.
Past Surgical History: The patient denied having any surgical procedures performed on him.
Current psychotropic medications:
________________None_________________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
Current prescription medications:
_______________________None__________________ ________________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
____________________None_____________________ ________________________________
_________________________________________ ________________________________
Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
| Substance | Amount | Frequency | Length of Use |
| Alcohol | 4 bottles of beer | Everyday | one month |
| Cigarettes | 1 pack | Everyday | 1 year. |
| None | None | None | None |
| None | None | None | None |
Family Psychiatric History: _
- The patient admitted that his father died when he was 54 years old due to drunken driving. The patient admitted the father was diagnosed with major depressive disorder and alcohol use disorder.
- The patient admitted his mother is still alive and she is 48 years old. He admitted his mother was diagnosed with obsessive-compulsive disorder but does not remember the date,
- The patient admitted his older brother who is currently 30 years old was diagnosed with generalized anxiety disorder when he was 15 years old.
- The patient admitted his paternal grandfather passed away due to lung cancer. The patient admitted that his grandfather had a history of schizophrenia.
____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ____Patient lives in a two-bedroom apartment with girlfriend_______ Marital Status: __Single______
Education: __________ Bachelor of Arts in Architectural Studies__________
Employment Status: __Employed____ Current/Previous occupation type: __________Architecture_______
Exposure to: Smoke__ Admits to smoking one pack of cigarette each day__ ETOH _Admits to drinking 4 bottles of beer each day___ Recreational Drug Use: ________None__________
Sexual Orientation: ____Heterosexual___ Sexual Activity: _Active___ Contraception Use: _________Condom___
Family Composition: Family/Mother/Father/Alone: Mother, and older brother. Patient recently lost father due to car accident.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx):___The patient admitted he was born in Miami, Florida in 1998.The patient admitted he had always been an active and happy child and often enjoyed playing soccer with his friends after school and on the weekends. The patient admitted that he currently lives in a 2-bedroom apartment with his girlfriend. He admitted that he likes to play chess as a hobby and also enjoys hiking. The patient admitted that he makes friends easily and therefore has a lot of friends. The patient denied a having a history of abuse or violence.
Health Maintenance
Screening Tests:
The patient denied undergoing any screening tests.
- The patient admitted to being up to date with his annual checkups with the last check up being on the 3rd of November 2022 and the next visit being on the 3rd of November 2023.
- The patient admitted that he gets routine dental checkups every 6 months with the last visit being on the 10th of June 2022 and the next visit being on the 10th of June 2023.
- The patient admitted to putting on his seat belt when driving and does not drink and drive.
- The patient admitted to having an annual eye exam but has not been consistent in the past year.
Exposures: The patient admitted to having an exposure to smoke
Immunization HX: The patient admitted to being current with his immunizations except the influenza vaccine which he does not recall the date of his next visit.
Review of Systems:
General: The patient admitted to being anxious, paranoid, scared. He admitted to seeing and hearing people plotting to kidnap him.
HEENT: The patient denied experiencing headaches, having a history of head injury, or experiencing baldness. The patient denied having issues with his sight, having a history of eye infections, or eye discomfort. The patient denied having nasal congestion, runny nose, sneezing, or history or allergies. The patient denied having mouth sores, missing teeth, decayed teeth, bleeding gums, bad breath, throat inflammation, or soreness.
Neck: The patient denies having neck restrictions, pain, lumps or neck trauma.
Lungs: The patient denies having a cough, chest discomfort, sputum output, wheezing, or breathing issues.
Cardiovascular: The patient denies any chest pain, breathlessness, edema in the lower limbs, or palpitations.
Breast: The patient denied noticing any breast deformity, enlargement, sores, or having breast trauma
GI: The patient denies abdominal pain, bloating, reflux, constipation or diarrhea.
Male/female genital: The patient denied penile pain, discharge, sores, or injury
GU: The patient denies having issues with urinating, frequency, urgency, or blood in urine
Neuro: The patient denied experiencing any migraines, numbness, loss of balance or fainting spells.
Musculoskeletal: The patient denies joint pain, swelling, injury, or muscle spasms.
Activity & Exercise: Patient admits he likes to ride his bicycle every morning before work for 2 miles but he has not been able to do that for 4 days due to fear of being kidnapped.
Psychosocial: The patient admitted to feeling highly paranoid, anxious, and frightened. He admits to hallucinations both auditory and visual
Derm: The patient denied having any skin color changes, dry skin, scars, bruises or sores.
Nutrition: The patient admitted to being a vegetarian and his meals consist of mostly vegetables, and fruits.
Sleep/Rest: The patient admitted to never having trouble sleeping and usually gets 8-9 hours of sleep each night. The patient admitted he has been having trouble sleeping for 4 days now due to fear of being kidnapped.
LMP: N/A
STI Hx: The patient denies having a history of sexually transmitted infections, penile infections, or urinary tract infections.
Physical Exam
BP_____149/89 measured on the left arm in a seated position___TPR___97.3F taken orally__ HR: _80____ RR: ___20_Ht. _6’3____ Wt. _70 kg_____ BMI (percentile) 19.3 kg/m2 (Normal). Pain: No pain indicated at this time
General: He is a young man who walks normally but with a worried appearance, and he is slightly disheveled. In terms of place, time, and people, he is awake, attentive, and oriented, but not in terms of the day of the week.
HEENT: Head: Non-traumatic, even hair dispersion, no mounds or discomfort on palpation, no bruises or swellings, and no nits or dandruff on the hair. Eyes: Symmetrical eyes. pupils constricted by 2 mm. Conjunctiva and sclera are clear, extraocular motions are intact, there is no eyelid erythema, the visual field is undamaged, and the visual acuity is acceptable. Ears: Symmetrical, without wax buildup or unusual discharge. a Tympanic membrane in gray. has good hearing in both ears. Nose: Clear nasal nares, no hemorrhage, no infections, no drainage, and no distorted septum. No indications of a sinus issue. Inner nose is smooth, clean, and attractive. Mouth: Tongue and mucosa are pink, teeth are unbroken, there are no abscesses or lesions, both tonsils are intact, and the gag reflex is active. Gums are pink, and no bleeding is seen.
Neck: Supple, with a typical full range of motion, no marks or pustules, no misaligned trachea, no pain, and no perceptible lumps.
Pulmonary: The chest expands and contracts with breathing, there are no marks or malformations, no soreness, equal bilateral tactile fremitus, and typical breath noises are all present.
Cardiovascular: Peripheral pulses are palpable and they are 2+ bilaterally with a regular speed, volume, and rhythm, and S1 and S2 were audible with no additional sounds. There are no chest scarring or distortions, jugular distention, swelling, or discomfort.
Breast: No breast deformity noted, no breast enlargement, sores, lumps, or injury noted
GI: stomach that is flat, not bloated, and free of bruises or scars. On palpation, there were no masses, swellings, or suprapubic pain related to the bladder.
Male/female genital: The color of the penis is appropriate, there are no lumps or bumps, no discharge, no open cuts or sores, and there are no indications of infection. Penis circumcised
GU: No report of urinary leakage, incontinence, blockage, frequency, or pain on urination.
Neuro: All of his cranial nerves are intact, he has intact sensation, is oriented to person and place, speaks with pressure, and is unable to maintain eye contact, all of his muscle groups have typical muscle tone and power.
capable of switching between tables, able to detect any touch on his arms, face, or finger.
Generally balanced gait.
Cerebellar sign; able to touch his mouth, ear, and mouth when told to, despite an unbalanced gait.
Musculoskeletal: Zero joint swelling, skeletal abnormalities, lost limbs or fingers, discomfort or swelling when palpating any joints, and appropriate range of motion with no resistance in any joints.
Derm: The patient’s skin tone indicates his ethnicity. He had warm, moist skin. There are no reports of any changes in his skin. No lesions, bruises, or swellings were observed.
Psychosocial: The patient is awake and alert to person and place. He is unable to maintain eye contact, his speech is rapid and pressured. He displays signs of hallucinations, paranoia, anxiety, and impaired clinical insight and judgment.
Misc. N/A
Mental Status Exam
Appearance: Although the patient’s appearance was unkempt, there was no odor and had adequate cleanliness.
Behavior: The patient showed signs of restlessness and agitation.Also, the patient displayed strange behaviors, such as talking to himself.
Speech: Incoherence and loose association were evident in the patient’s speech.He was also talking quickly and continuously, which resulted in pressure in his speech.
Mood: The patient admitted feeling anxious, scared and paranoid.
Affect: The patient’s affect was improper, as evidenced by the fact that his emotional expression did not correspond to the content of his discourse.
Thought Content: The patient’s thought process exhibited derailment, as his ideas veered off course and into completely unrelated ones. He also displayed symptoms of thought obstruction.
Thought Process: The patient displayed delusional thoughts because he thought he was being followed and observed. He also admitted to having visual and auditory hallucinations.
Cognition/Intelligence: The patient had distorted perception, seeing things that were not there.
Clinical Insight: impaired as he did not believe there was anything wrong with him.
Clinical Judgment: Impaired as he has poor judgment due to his delusions and hallucinations
|
Plan
The Positive and Negative Syndrome Scale (PANSS).
In 1987, Stanley Kay, Lewis Opler, and Abraham Fiszbein released the Positive and Negative Syndrome Scale (Druss et al., 2018). The scale was used to gauge how severe the patient’s schizophrenia symptoms were.
Differential Diagnoses
- Schizophrenia Disorder DSM-5 295.90 (F20.9)
- Bipolar Disorder DSM-5 296.89 (F31.81)
Manic depression, formerly known as bipolar disorder, is a mental health illness that results in rapid mood swings, including emotional highs (mania or hypomania), and lows (Henderson et al., 2020). Either bipolar 1 or bipolar 2 might be present in a person. The patient’s symptoms are suggestive of bipolar 1 disorder, which is marked by symptoms including flying from one concept to another rapidly, rapid, pressured and loud speaking, erratic behavior, hyperactivity, increased energy, decreased need for sleep, inflated sense of self, and substance abuse. This disorder is ruled out using the PANSS screening method.
Principal Diagnoses
- Schizophrenia Disorder DSM-5 295.90 (F20.9)
Schizophrenia is a severe mental illness that causes hallucinations, delusions, and
profoundly disordered thought and behavior that make it difficult for sufferers to carry out daily tasks(Keepers et al., 2020).The DSM-5 criteria states that for paranoid schizophrenia, a person must demonstrate symptoms such delusions, hallucinations, disordered or incoherent speaking, disorganized or odd movements, and negative symptoms in order to be diagnosed with schizophrenia.
Treatment Plan
The patient has been identified as having paranoid schizophrenia, and his treatment plan will include both psychotherapy and medication. Amisulpride 400mg was prescribed for the patient to take orally once daily. By blocking presynaptic dopamine D2 and D3 receptors, amisulpride 400 mg can help lessen the negative symptoms of schizophrenia. Amisulpride 50 mg costs approximately $0.75 per tablet for 100 tablets.
Cognitive behavioral treatment was advised for the patient in order to assist him improve his social and problem-solving abilities, lessen the severity of his symptoms, and lower his risk of relapsing.
Education
The patient was instructed to call the doctor right away if he experiences any heart rhythm problems, such as fast, pounding, or irregular heartbeats, because amisulpride may alter how the heart beats and cause fainting or dangerous adverse effects in some patients.
Diagnosis #1 Schizophrenia
Diagnostic Testing/Screening: The Positive and Negative Syndrome Scale (PANSS).
Pharmacological Treatment:
Name: Amisulpride
Dosage: 400 mg
Route: Taken orally
Frequency: Once a day
Estimated Price: Amisulpride 50 mg costs approximately $0.75 per tablet for 100 tablets.
Non-Pharmacological Treatment: Cognitive Behavioral Therapy
Education:
- Even if he feels better, the patient was advised to take his medication as directed.
- Even if he experiences side effects, he was advised to continue taking his medication because they are frequently manageable.
- He was advised to Show up to all of his mental health provider’s follow-up appointments.
- Steer clear of drugs and alcohol, which can exacerbate symptoms and reduce the efficacy of medication.
- Get plenty of sleep and adopt healthy sleeping habits.
- Maintain both physical and mental health by eating a healthy, balanced diet.
Referrals: Psychotherapist
Follow-up: 1 week to evaluate symptoms and medication adherence
Anticipatory Guidance:
- Maintain physical and mental health by following a healthy, balanced diet.
- Engage in regular exercise to help him feel better and be less stressed.
3.Avoid stressful circumstances or develop coping mechanisms for handling stress.
- Engage in self-care practices like writing, meditation, or slow, deep breathing.
- Get familiar with the early indicators of recurrence and notify your mental health professional of them.
- Create a solid network of relatives, friends, or peers who can offer emotional support.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
References
Druss, B. G., Chwastiak, L., Kern, J., Parks, J. J., Ward, M. C., & Raney, L. E. (2018). Psychiatry’s role in improving the physical health of patients with serious mental illness: a report from the American Psychiatric Association. Psychiatric Services, 69(3), 254-256. https://doi.org/10.1176/appi.ps.201700359
Henderson, T. A., Van Lierop, M. J., McLean, M., Uszler, J. M., Thornton, J. F., Siow, Y. H., … & Cohen, P. (2020). Functional neuroimaging in psychiatry—aiding in diagnosis and guiding treatment. What the American Psychiatric Association does not know. Frontiers in Psychiatry, 11, 276. https://doi.org/10.3389/fpsyt.2020.00276
Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., … & (Systematic Review). (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry, 177(9), 868-872. https://doi.org/10.1176/appi.ajp.2020.177901
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)__________S.S.____________________ Age _______25____
Date: ________18/03/2023_______
RX ______ Amisulpride.
SIG: 400 mg to be taken orally once a day. Amisulpride 50 mg costs approximately $0.75 per tablet for 100 tablets.
Dispense: ______400 mg_____ Refill: ______0___________
No Substitution
Signature: ____________________________________________________________
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