Soap Essay Paper
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. Soap Essay Paper
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
- Anxiety Disorder F41.9
Rational: patient with anxiety disorders often experience low mood.
- Persistent depressive disorder 1
Rational: patients with this condition often present with loss of interest in normal activities and low mad
P:
- Discontinue Paxil 30mg/day
- Prescribe Lexapro 20mg/day
Rational: Lexapro has a more tolerable side effect profile in treating depression
- Laboratory testing: NA
- 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.
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 behaviors. 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.
A:
DSM5 Principal Dx: Post-traumatic stress disorder F43.1
Differential diagnosis
- Acute stress disorder F43. 0
Rational: patients with PTSD often experience sleep disturbances and nightmares.
- Major depressive disorder F33.1
Rational: Patients with depression often experience suicide ideation.
- Anxiety disorder 9
Rational: Patients with anxiety disorder often get repeated flashbacks of traumatic experiences
P:
- 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.
- Start trauma-focused cognitive behavioral therapy
Rational: trauma-focused cognitive behavioral therapy improves coping techniques so that a person can better react to reminders of the traumatic experience and the emotions connected with it.
- 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
Patient to follow up in 4 weeks to evaluate symptoms.
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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
A:
DSM5 Principal Dx: Bipolar disorder type 1 F31. 1
Differential diagnosis
- Schizophrenia F20. 9
Rational: patients with Schizophrenia often report sleep problems and hearing voices.
- Major depressive disorder F33.1
Rational: Patients with depression often experience feelings of self-harm.
- Schizoaffective disorder 9
- Rational: Patients with Schizoaffective disorder often engage in risky behaviors
P:
- Continue Topamax and Vistaril
Rational: The patient reports that these medications have been effective
- Start cognitive behavioral therapy
Rational: CBT will help the patient develop coping skills
- 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. Soap Essay Paper
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
- Anxiety Disorder F41.9
Rational: patient with anxiety disorders often experience sad mood.
- Historic personality disorder 4
Rational: The patient’s condition might have been inherited from her parents
P:
- Refer to counseling at least twice a week
- Provide various resources and emergency numbers.
- Laboratory testing: NA
- 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
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
- Major depressive disorder F33.1
Rational: patient reports depressed mood and feelings of worthlessness
- Drug induced mood disorder
Rational: Patients with cocaine use disorder may develop depressive symptoms.
P:
- Prescribe fluoxetine 20mg PO QAM
Rational: fluoxetine has less side effects
- Begin CBT, group therapies and individual therapy sessions
Rational: these therapy techniques will help the patient stay clean and cope with life
- 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
- Follow up
Patient to follow up in 2 weeks
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. Soap Essay Paper
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
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. Soap Essay Paper
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
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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. Soap Essay Paper
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. Soap Essay Paper
