Psychiatric SOAP Notes for clinicals Essay Assignment Paper

Soap 1:

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

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 Essay Assignment Paper

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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. Psychiatric SOAP Notes for clinicals Essay Assignment Paper

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

Differential diagnosis

Acute Stress Disorder F43.0

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

General Anxiety Disorder (GAD) F41.1

Rational: this condition is often associated with excessive worry and sleep problems.

Zoloft 50mg once daily

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

Laboratory testing: NA
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

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.”

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.

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.

DSM5 Principal Dx: Schizophrenia F20.9

Differential diagnosis

Delusional Disorder Persecutory Type F22

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

Bipolar Disorder with Psychotic Features F31.2

Rational: Patients with this disorder often experience delusions during depressive episodes. Psychiatric SOAP Notes for clinicals Essay Assignment Paper

Prescribe Clozapine 12.5 mg once daily

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

Start cognitive behavior therapy

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

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

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.”

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.

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.

DSM5 Principal Dx: Psychoactive substance abuse F19. 10

Differential diagnosis

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.

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

Start counseling

Rational: counseling provides necessary support system for the patient

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

Follow up

Patient to follow up in 2 weeks

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Soap 4

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

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. Psychiatric SOAP Notes for clinicals Essay Assignment Paper

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

DSM5 Principal Dx: Insomnia G47.00

Differential diagnosis

Generalized Anxiety Disorder F41.1

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

Obstructive Sleep Apnea G47.33

Rational: patients with sleep apnea often experience difficulty staying asleep

Recommend cognitive behavioral therapy

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

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

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.”

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.

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

DSM5 Principal Dx: Obsessive-Compulsive Disorder F42

Differential diagnosis

Body Dysmorphic Disorder 22

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

Obsessive-compulsive personality disorder F60.5

Rational: Patients with this disorder exhibit extreme perfectionism

Prescribe Clomipramine 25 mg once daily

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

Begin CBT

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

Patient education

– Patient educated on being compliant with the treatment regimen

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

Follow up

Patient to follow up in 2 weeks

NURSING ASSESSMENT TOOL

Student: Date:

Patient’s Age 68 Gender: Male�Female�

ALLERGIES (Drugs, food, tape, dyes, latex, etc) yes no X (If yes) Specify: Ampicillin

Describe reaction(s)

rash

,Reason for admit COPD exacerbation and pneumonia

Admit diagnosis

COPD and pneumonia

Surgeries/Procedures (current)

Other medical diagnoses none

none

Previous hospitalizations/surgeries/year _UTO

Ancillary consults (therapy, dietary, social services, child life, etc.) UTO

Advanced Directives: Living will DNR Other

UTO

Isolation: yes no X (If yes) type

Restraints in use: yes no X (If yes) Restraint protocol *see attached

HEALTH PERCEPTION/HEALTH MAINTENANCE PATTERNS

General appearance_pleasant male Immunizations up-to-date: yes X no If no, explain

Received the Flu vaccine yes no UTO TDAP yes no UTO Pneumonia Vaccine yes no UTO Recent illness/exposure to communicable disease _ UTO

Strategies done to manage health _ none

Use of: Tobacco yes no (If yes) How long

UTO How much

UTO

Motivation

ETOH yes no (If yes) How long

UTO How much

UTO

Other illicit substance(s) use: none

Complementary Alternative Medicine (CAM) use: none

Medications (Current Prescription, OTC, & CAM)

Drug/Dosage/Route/Frequency) Psychiatric SOAP Notes for clinicals Essay Assignment Paper

Drug/Dosage/Route/Frequency

Cetriaxone I g IV bolus every 12 hours

Nicotine 21 mg T daily

Methylprednisolone 40mg IV bolus Q 12hr

Salmaterol 1inhalation every 12hr

Albuterol 2.5 mg every 4 hr

Home medication compliance/noncompliance _ compliant

*see attached

Laboratory Data (Identify labs: High=H, Low=L, Critical =C, *** = Trend)

blanks are for other pertinent labs

DAY:à					DAYà
Test:â	Day 1	Day 2	Day 3	Current:	Test à	Day 1	Day 2	Day 3	Current:
RBC	—-–	—-–	—-–	4.8	Na	—-–	—-–	—-–	135

WBC

—-–

—-– 8

K —–

—-–

9.3

Hemoglobin

—-–

—-– 9.3

BUN

—-–

—-– 22

Hematocrit

—-–

—-– 29

Creatinine

—-–

1.0

Platelets

—-–

162

Glucose

—-–

180

INR

—-–

0.9

Triglycerides

—-–

PT —–

—-–

Total Chol.

—-–

PTT

—-–

HDL/LDL

—-–

Albumin

—-–

BNP

—-–

CO2 —-–

MICROBIOLOGY CULTURE RESULTS VITAL SIGN FLOWSHEET

Specimen

Urine

24 hour results

—-–

48 hour results

—-–

72 hour results

—-– HR

Day 1

—-–

Day2

—-–

Day 3

—-–

Current: 88

Sputum

Blood

—-–

BP —–

RR —–

—-–

150/96

Wound

CSF

—-–

Temp

SpO2

—-–

99 .4

Other

—-–

Diagnostic Tests

(Admit, Day 1, Day 2, Day 3, Current/RESULTS)

Chest X-ray —-

*blanks are for other diagnostic tests

EKG —-

CT scan —-

MRI —-

Ultrasound —-

Other X-ray AP Pelvis and Hip: Left intertrochanter hip Fx *see attached

Nutritional/Metabolic Patterns/ ID Wounds (numbered refer to in form), IV sites, incisions, drains, etc.

Height_173cm

Current weight_156lbs

Admit weight_UTO

BMI

Last 3 daily weights —-– —-– —-–

Current diet_ UTO

Supplements UTO Restrictions _none

Pattern of intake at home_ UTO

Appetite_ UTO Anorexia no Nausea/vomiting: _denies

Energy level

low

Recent wt.loss/gain

UTO

Condition of mouth/throat: _membranes intact; shows no signs of dehyration Difficulty swallowing: no signs of dysphagia_ Problems chewing UTO Dentures: None Full Partial Wears them? yes no UTO

Restrictions: NPO after midnight the night before Sx Fluid Restriction_none

Upper GI distress (describe) _UTO

NG/PEG/Dobhoff (circle one) suction Enteral nutrition (type/rate)

character Flush

Tube feeding residuals

TPN (type/rate) —-

IV fluids (type/rate)_none

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Skin: Moisture_dry

Turgor Bruises

none

Pruritus none

Edema _none Incisions none Rash yes Wounds none IV sites — Type: _UTO Central PICC Peripheral Condition: Dialysis access sites none Thrill Orthopedic devices none				Bruit_—-
Other data				*see attached

Intake	Admit	Day 1	Day 2	Day 3	Day 4
Oral		Water 250mL
IV Fluids
Tube feeding
*
24 hr total		575mL
Output	Admit	Day 1	Day 2	Day 3	Day 4
Urine		300mL, 300mL
NG
Stool
Drain 1
Drain 2
Dialysis
Diaper
*
24 hr total		600mL

Running Balance (difference in total intakes and total outputs since admission) (+ / -) -25 fluid deficit

*Indicate other intake/output; Stool (liquid/colostomy) *see

attached

Elimination Patterns

Bowel habits: #BMs/day_2 Last BM <24 hours/25-36 hours/37-48 hours/>2 days UTO

Usual pattern

UTO

color

UTO

consistency_formed

Constipation_UTO

Diarrhea (#/day)_ UTO

Incontinence_no

Flatus

—-

Occult blood

—-

Recent

changes —-

Ostomy: Type

—-

Appliance

—-

Self care?

Stoma condition

—-

Stool appearance

UTO

Use of laxatives, enemas, etc (what & how often) _docusate sodium 100mg orally once daily

Abdominal PE: Contour Firmness X Describe

Pain

none

Bowel sounds

UTO Quads

Abd girth

UTO Ascites no

Other

Bladder habits: WNL_X

Frequency—-

Dysuria_—-

Nocturia —-

Urgency_—-_ Hematuria_—-

Retention

—-

Incontinent: Yes No X (if yes): Always Occasional Daytime Nighttime Difficulty reaching toilet

Assistive devices: Catheter no

Diapers

Comments

Urine: Color

UTO Odor

UTO Clarity

UTO Sediment

UTO

Dialysis : Yes No X (if yes) type

—-

how often

—-

Other pertinent data

*see attached

Activity – Exercise Patterns

Activity level/pattern (prior to admit)

UTO

Exercise

habits UTO

History of physical disability UTO Uses assistive devices UTO

Current activity level (orders) _Bedrest Falls risk rating _45 Restraints_none

Range of motion: Full Other

Ability to walk yes Balance and gait: Steady UTO Unsteady UTO

Casts/splints/braces none Fractures/contractures/arthritis/other hip

fracture

Verbalizes fatigue or weakness _no General_— Focal_—

Observed responses to activity (SOB, inc. pulse, B/P, etc) _UTO SPO2 :Before UTO After UTO

ADL STATUS*

*Feeding _UTO *Meal preparation _UTO *Cleaning _UTO *Bathing _UTO

*Dressing UTO

*Grooming _UTO *Toileting _UTO *Shopping _UTO *Laundry _UTO Handedness: Right Left Able to use?

UTO

Physical or Occupational Therapy consult

*ADL Code (current status):

0 Total independence

1 Requires device assistance

2 Requires 1 person assistance

3 Requires device and person assistance 4 Total dependence

UTO

Other pertinent data _may need home health care

Cardiovascular Status

BP: RA —- LA —- Sitting —- Lying —-

Standing —-

Pulse: Apical _88bp /min Radial _89bp /min Strong X Weak

Peripheral: pulses: R upper: L upper: R lower: L lower:

Nail bed color_pink Capillary refill_<2 sec Temperature Moisture

Edema none present Sensation _yes JVD UTO

Skin color: WNL X Pale Cyanotic Flushed Other

Mucous membranes: Pink X Pale Cyanotic Other intact

Heart sounds: UTO S3 UTO S4 UTO Other

Hx of murmur UTO A-V bruit UTO

Pacemaker UTO If yes, type & settings —-

Telemetry Yes No (if yes) cardiac rhythm

DVT prophylaxis regimen (describe)_ UTO

Other pertinent data _ UTO

Respiratory Status

Rate 15bpm Quality: Depth deep Rhythm_even, bilaterally Accessory use none

Retractions: Type UTO Severity UTO

SOB on exertion (type activity) Yes UTO SOB at rest_Yes Cough Yes Sputum (describe)_green sputum_

Best position for breathing UTO O2

supplements none

Breath sounds: (describe all lung fields): R upper anterior UTO R lower anterior UTO

L upper anterior UTO L lower anterior UTO – R upper posterior UTO R lower posterior UTO

L upper posterior UTO L lower posterior UTO

Airway adjuncts —-

Secretions none

Chest tubes: location no settings —- drainage —-

ABG’s: pH —- PO2 —- PCO2 —- Bicarb (HCO3)_—- O2 Sat —-

Other pertinent data *see attached

Sleep-Rest Patterns

Usual patterns: hours/night _ UTO AM nap _ UTO PM nap _ UTO Bedtime rituals/sleep patterns UTO Methods to promote sleep UTO Feel rested after sleep UTO

Problems: Recent changes UTO Insomnia UTO Snoring UTO Hypersomnia UTO Sleep Apnea UTO Nightmares UTO Other_

Sleeps in: Crib —- Bed Specialty Bed no Other pertinent data

*see attached

Cognitive/Perceptual Patterns

Cognition

Level of education UTO Primary Language UTO Able to speak English yes

Abnormal thought processes UTO Memory loss (short/long term) UTO Meeting Developmental Milestones UTO

Other pertinent data

UTO

Sensation

Hearing: WNL UTO Impaired _ UTO Deaf no Hearing aid UTO Tinnitus _ UTO

Vision: WNL X Impaired Glasses UTO Contact lenses UTO Cataracts UTO

Prosthesis(R/L) UTO Lens implants(R/L) UTO Glaucoma UTO

Taste: WNL Impaired UTO

Smell: WNL Impaired UTO Touch: WNL Impaired UTO

Numbness/tingling —- Dizziness_ UTO Vertigo_ UTO Other pertinent

data

*see attached

Neuro Sensory

Mental Status: Alert_X Oriented (x 4_) Receptive aphasia _no Confused _ no Combative _ no

Obtunded_ no Unresponsive _ no

Speech: WNL X Slurred no Garbled no Expressive aphasia no

Pupils: Equal X Unequal X Size: (R) 5cm (L) _5cm React to light: (R) _ X (L) X Accommodation

X _

Other (surgeries,

etc) UTO

Reflexes: DTR’s: UTO Superficial: UTO

Movement & strength of extremities: R upper X L upper X R lower X L lower_decreased

Seizure activity: no Type —-

Fontanel (infants only): soft/flat_n/a full/tense n/a depressed n/a

Restraint Use n/a

data *see attached
Pain/Comfort Acute pain: location UTO intensity (rating) UTO quality_ UTO duration UTO pattern UTO Chronic pain: location osteoporosis intensity (rating)_ UTO duration UTO pattern UTO Type of Pain Scale _ UTO Precipitating factors UTO Aggravating factors UTO Accompanying symptoms UTO Pain relief measures UTO Satisfaction with relief (pain rating, etc.) UTO CA pump (medication, dosage, pump settings) none Other discomforts _none Relief measures_ UTO Other pertinent data
SELF PERCEPTION/SELF CONCEPT/COPING-STRESS TOLERANCE PATTERNS
Major concerns regarding hospitalization/illness/perceived self concept possibly he will no longer be able to do ADLs Major losses in last year UTO Major life changes in last year UTO Body image changes_ UTO (may now have to use a walker, cane) Changes in abilities/role UTO Emotional state: Calm _ Cheerful Euphoric Anxious Withdrawn Sad X Irritable Demanding Stressors UTO (possibly dizzy spells) Usual methods for stress management UTO Relaxation techniques UTO Other pertinent data *see attached
SEXUAL/REPRODUCTIVE PATTERNS
Female: Pregnancies _ Children _ LMP Menopause Menstrual problems Last mammogram Monthly self breast exams: Last pap smear Vaginal discharge Lesions Bleeding Male: Last prostate exam 1-6 months/6-12 months/1-2 years/> 2 years. Monthly self testicular exam: yes� no� History of STI UTO Sexual concerns UTO Other pertinent data: none
Role-Relationship Patterns
Occupation: UTO Employment status UTO Marital status: Single Married Separated Divorced Widowed UTO Support systems: Spouse Family in same residence UTO Family not in residence daughter Neighbors/friends UTO Parents Involved(if patient is a minor) —- Visiting _—- Educational level: UTO Educational level of parent (if patient is a minor)_—- Family concerns regarding hospitalization: _at risk for falls Changes in roles/relationships UTO Other pertinent data: _ may need in home health and monitoring *see attached Psychiatric SOAP Notes for clinicals Essay Assignment Paper

Value-Belief Patterns
Cultural/ethnic background _Latino Denomination Christian Life goals/values UTO Spiritual values/beliefs which influence health UTO Request pastoral care/support person possibly daughter Other pertinent data: none
Discharge Planning & Teaching Needs
Anticipated D/C date: cannot anticipate discharge date Discharged to_ UTO (possibly daughter) Lives with UTO Major caregiver Daughter Available help at home UTO Anticipated self-care problems post-discharge _deep breathing exercices Previous use of community resources UTO Insurance Status: Assistive devices needed UTO Home Medical Equipment UTO Need for community resources post discharge _Home health and physical therapist Referrals made at discharge: (record date) none Other pertinent data: none
Teaching Needs: 1) Smoking cessation 2) Risk for falls 3) Deep breathing exercises 4) Rest between activities

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Diagnostic Tests

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Elimination Patterns

Bladder habits: WNL_X

Activity – Exercise Patterns

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