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DEMOGRAPHICSPatient Initials:
N/A
Age:
17 YEARS
Sex:
FEMALE
Race/Ethnicity:
WHITE
SUBJECTIVE
CHIEF COMPLAINT (CC):
FEELING WEAK AND TIRED
HISTORY OF PRESENT ILLNESS (HPI):
THE PATIENT HAS BEEN ILL FOR THE PAST ONE WEEK
PAST HISTORY
PMH:
THE PATIENT HAS BEEN FEELING UNWELL FOR THE LAST ONE
WEEK. SHE HAS TAKEN AMOXICILLIN 2-3 TIMES PER DAY
PSH:
N/A
PSYCHIATRIC HISTORY:
N/A
FAMILY HISTORY / SOCIAL HISTORY
FAMILY HISTORY (FH):
HER SISTER FELL ILL THE PREVIOUS MONTH
SOCIAL HISTORY:
HER FRIENDS AND TEAM MEMBERS HAVE BEEN SICK FOR A
COUPLE WEEKS
MEDICATION RECONCILLIATION / REVIEW
MEDICATIONS & INDICATIONS:
(Prescribed & OTC)
ACETAMINOPHEN OR NSAID SUCH AS NAPROXEN, IBUPROFEN
AND ANTIBIOTICS SUCH AS AMOXICILLIN OR PENICILLIN
ALLERGIES / IMMUNIZATIONS
ALLERGIES:
N/A
IMMUNIZATIONS:
N/A
HEALTH PROMOTION / HEALTH MAINTENANCE
NUTRITION / DIET:
THE PATIENT SHOULD MAJORLY TAKE FLUIDS AND TENDER
MEALS SUCH AS COOKED PASTA AND MASHED POTATOES
EXERCISE REGIMEN:
TOBACCO/ALCOHOL/
ILLICIT DRUG USE:
SAFETY MEASURES:
THE PATIENT SHOULD TAKE PART IN REGULAR PHYSICAL
EXERCISES. SHE SHOULD NOT MIX WITH OTHERS DURING SUCH
EXERCISES
THE PATIENT SHOULD AVOID TOBACCO, ALCOHOL, AND OTHER
ILLICIT DRUGS SINCE THEY ARE IRRITANTS THAT MAY MAKE HER
CONDITION MORE SEVERE
THE PATIENT SHOULD SELF-ISOLATE TO AVOID INFECTING
OTHERS
SCREENINGS / EXAMS:
THE PATIENT IS SCREENED USING LIGHTENED DEVICE TO CHECK
HER THROAT, MOUTH, AND EARS.
REVIEW OF SYSTEMS
CONSTITUTIONAL / GENERAL:
USE A LIGHTED INSTRUMENT TO CHECK THE THROAT, THE EARS,
NASAL CAVITIES, AND THE EYE.
EYES:
VISUAL CHANGES, EYE PAIN, OR DRY EYES
EARS/NOSE/MOUTH/THROAT:
EAR INFECTIONS, HEARING LOSS, RINGING EARS, HOARSE
THROAT, SINUS PROBLEMS, AND PROBLEMS WITH
SWALLOWING
CARDIOVASCULAR:
SWOLLEN FEET, FAINTING, HEART MURMUR, OR CHEST PAIN
RESPIRATORY:
WHEEZING, PERSISTENT COUGH, OR BLOODY SPUTUM
GASTROINTESTINAL/ABDOMEN:
BLOOD IN STOOL, ABDOMINAL PAIN, SWALLOWING PROBLEMS,
NAUSEA, OR HEARTBURNS
GENITOURINARY:
MENSTURAL CHANGES, PAINFUL URINATION, BLOODY URINE,
OR ERECTILE DSYFUNCTION
MUSCULOSKELETAL:
JOINT SWELLINGS, JOINT PAIN, ARTHITIS, STIFFNESS, CRAMPS,
OR MUSCLE PAIN
INTEGUMENTARY:
RASH, ITCHING, CHANGE IN SKIN COLOR, DISCHARGES FROM
THE SKIN, OR NEW LESIONS
NEUROLOGICAL:
DIZZINESS, DEMENTIA, SPEECH DELAY, SEIZURES, DELAYED
MOTOR TECHNIQUES, CONFUSION, HEADACHES, TREMORS,
WEAKNESSES, SLURRED SPEECH, NUMBNESS, OR POOR
BALANCE
PSYCHIATRIC:
ANXIETY/TENSION, DEPRESSION, MEMORY LAPSES, INSOMNIA,
PREVIOUS TREATMENT WITH A PSYCHIARIST, MOOD SWINGS
ENDOCRINE:
FATIGUE, HYPERACTIVITY, EXCESSIVE HUNGER, EXCESSIVE
THIRST
HEMATOLOGIC / LYMPHATIC:
EASILY BRUISES, EASILY BLEEDS, OR SWOLLEN LYMPH NODES
ALLERGIC / IMMUNOLOGIC:
ALLERGY TO EGGS, SHRIMPS, OR SEASONAL ALLERGY
OBJECTIVE
VITAL SIGNS: FEVER, SORE THROAT, TONSILLAR EXUDATES, NO COUGH, DIFFICULTY SWALLOWING, LOW
BLOOD PRESSURE, WEIGHT LOSS
T:
100.1F
HR:
90
BP: 118/80
Height: N/A
mm/Hg RR:
Weight: NO CHANGE IN WEIGHT
18 PER
MINUTE
O2:
N/A
BMI: N/A
PHYSICAL EXAM
CONSTITUTIONAL / GENERAL:
THE PHYSICAL EXAMINATION WAS DONE USING A LIGHTED INSTRUMENT
TO CHECK THE THROAT, THE EARS, NASAL CAVITIES, AND THE EYE.
EYES:
EARS/NOSE/MOUTH/THROAT:
WHITE PATCHES ON THE BACK OF THE TONGUE AND THROAT
NECK:
HER NECK HS SWOLEN LYMPH NODES
RESPIRATORY:
HER BREATHING RATE IS LOW (18 PER MINUTE)
CARDIOVASCULAR:
HEART BEAT IS 90 BPM
CHEST / THORAX (BREASTS):
HER LUNGS ARE OKAY
GASTROINESTINAL /
ABDOMEN:
ENLARGED SPLEEN
GENITOURINARY:
N/A
LYMPHATIC:
HER LYMPH NODES ARE SWOLLEN
MUSCULOSKELETAL:
HER MUSCULOSKELETAL IS TENDER
INTEGUMENTARY / SKIN:
N/A
NEUROLOGIC:
HEADACHE AT THE FRONT OF THE HEAD
PSYCHIATRIC:
N/A
RESULTS REVIEW
ASSESSMENT
DIAGNOSIS (Dx)
1. TAKING PAIN-RELIEVING DRUGS LIKE PARACETAMOL, NAPROXEN, OR IBUPROFEN
DIFFERENTIAL DIAGNOSES
1. TAKING PLENTY OF FLUIDS, GARGLE WARM SALTWATER, HAVING ENOUGH REST, AND AVOIDING
IRRITANTS
PLAN
DIAGNOSTIC WORKUP
1. MONOSPOT TEST, CBCD, RAPID STREP TEST, THROAT CULTURE IF
INDICATED, NECK CT OR LATERAL NECK FILMS INCSASE MORE SEVERE
CONDITIONS ARE PRESENT
PHARMACOLOGICAL
1. ACETAMINOPHEN OR NSAID SUCH AS NAPROXEN, IBUPROFEN, CAN HELP
TREATMENTS:
CURE THE PATIENT OF THE SYMPTOMS.
2. ANTIBIOTICS SUCH AS AMOXICILLIN OR PENICILLIN ARE ALSO SIGNIFICANT
IN MANAGING SORE THROAT
3.
NON-PHARMACOLOGICAL 1. DRINKING PLENTY OF FLUIDS, TAKING ENOUGH REST, GARGLING
TREATMENTS:
SALTWATER, AVOIDING IRRITANTS LIKE TOBACCO SMOKE, AND
HUMIDIFYING THE AIR TO GET RID OF ALL DRY AIR.
REFERRALS:
THE PATIENT SHOULD SEE THE DOCTOR IF THE CONDITION GETS SEVERE,
HAS A FEVER OF MORE THAN 101 DEGRESS THAT LASTS FOR MORE THAN
ONE DAY, HAS RED RASHES, HAS SLEEPING PROBLEMS BECAUSE OF SORE
THROAT BLOCKED BY SWOLLEN ADENOIDS AND TONSILS.
EDUCATION:
Follow-up
IF THE PATIENT IS ALREADY ON MEDICATION, SHE SHOULD CHANGE HER
TOOTHBRUSH EVERY 48 HOURS AFTER THE START OF TREATMENT
FOLLOW UPS SHOULD BE DONE WITHIN 72 HOURS TO SEE IF THE
SYMPTOMS ARE IMPROVING
What would you do differently: Advice the patient to stay at home till her symptoms improve this
will help prevent infection to other people.
MN660 Case Study Psychiatric SOAP Note and Rx Template
Use this SOAP Note and Rx template to complete the Case Study. There are different ways in
which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This
is a template that is meant to guide you as you continue to develop your style of SOAP in the
psychiatric practice setting.
Criteria
Subjective
Include chief
complaint, subjective
information from the
patient, names and
relations of others
present in the
interview, and basic
demographic
information of the
patient. HPI, Past
Medical and
Psychiatric History,
Social History, Review
of Systems (ROS) – if
ROS is negative,
“ROS
noncontributory,” or
“ROS negative with
the exception of…”.
Clinical Notes
The patient is 26 years old college graduate. He is euthymic but with
a history of depressive episodes. Since he was a teenager, the patient
has experienced numerous episodes of major depression of varying
lengths and severity, most of which were not treated. Some of the
episodes disrupted his ability to work and attend school usually.
Past symptoms include depressed mood, disinterest in activities,
despondent thoughts, impaired cognition, insomnia, and poor energy.
Others include low self-esteem, rejection sensitivity, and feelings of
guilt. However, he reports that he has never had suicidal ideation.
The patient’s inter-episode recovery is good.
The patient has social anxiety, is nervous around strange people and
places, and has anticipatory anxiety, forcing him to shun social
events. The symptoms persist regardless of his affective state.
The patient’s mother has GAD. He has a negative ROS.
Objective
This is where the
“facts” are located.
Include relevant labs,
test results, vitals, and
physical exam if
performed. Include
NW_10/17/20
The patient’s vitals were as follows:
8
160/80
MSE, risk assessment
here, and psychiatric
screening measure
results.
76
18
5’10”
190lb
The patient is not currently on medication. He is neatly dressed,
clean, in his late 20s. He is Caucasian, with no involuntary
movement. His motor activity is coordinated; he appears engaged in
the current moment, makes eye contact periodically, and is calm.
He periodically gets lost in his thoughts and drifts, uses moderate
volume, and employs a combination of hand gestures, facial
expressions, and words appropriately. His answers are elaborate
without any stuttering but occasionally slow.
Assessment
Include your findings,
diagnosis, and
differentials (DSM-5
and any other medical
diagnosis) along with
ICD-10 codes,
treatment options, and
patient input
regarding treatment
options (if possible),
including obstacles to
treatment.
The patient has a generalized anxiety disorder. He is currently
between episodes and is exhibiting good recovery.
The adverse effects of SSRIs trigger manic episodes. The feasible
treatment options include psychotherapy (CBT or supportive therapy)
and pharmacological intervention.
Possible categories of medications include MAOIs, TCAs, and
atypical antidepressants. The patient is receptive to the treatment
options offered.
The patient’s ICD-10 codes are: F01-F99, F30-F39, F32.
Plan
Include a specific
plan, including
medications & dosing
NW_10/17/20
& titration
considerations, lab
work ordered,
referrals to
psychiatric and
medical providers,
therapy
recommendations,
holistic options and
complimentary
therapies, and
rationale for your
decisions. Include
when you will want to
see the patient next.
This comprehensive
plan should relate
directly to your
Assessment.
Determine the length of a previous manic episode (in days); if over
seven, evaluate for bipolar disorder; if under seven, continue the
GAD regimen.
SSRIs have proven ineffective in managing the patient due to the
unintended adverse outcome of triggering manic episodes.
The preferred drug for the management of GAD is amitriptyline, a
TCA, 20mg oral, BD.
Monitor efficacy of the drug for 48hrs. If the depressive symptoms
abate, discharge the patient and prescribe outpatient follow-up every
two days for one week, and after that twice weekly.
He was referred for cognitive-based therapy.
NW_10/17/20
PRESCRIPTION (for student use-Not VALID)
Purdue Global Medical Clinic
15 Medical Clinic Circle
Destination, SS, 00123
Phone: 123 456 7890
Fax: 123 456 7890
PMHNP Student Jane Purdue, APRN
License # SS 17245A
NPI # 1234567899
PATIENT DETAILS:
DATE: 06/02/2022
NAME
………………Patient
Doe……………………………………………………………..…..
DOB ……5/01/1996.………………………………………………………..
ADDRESS
……………3515 Admiral
Way……………………………………………………………
…………….Destination, SS
00123……………………………………………………..
Generalized Anxiety Disorder
Amitriptyline 20mg BD
___________________
Prescriber’s signature
NW_10/17/20
Correlating the patient’s history to bipolar disorder diagnosis
No, the patient’s history does not support a diagnosis of bipolar disorder. One of the
classic symptoms of bipolar is random changes in mood from depression to mania (Zimmerman
et al., 2019). Often, the patients have good recovery between the two extremes. Before taking the
prescribed serotonin reuptake inhibitors (SSRIs), the patient had experienced episodes of major
depression without mania. According to (Zimmerman et al., 2019), a patient must have had at
least one episode of mania before being diagnosed with bipolar disorder. However, the manic
episode must last at least one week to be of diagnostic significance. In this case, the patient
previously suffered major depressive episodes repeatedly but had not had a manic episode before
taking the prescription. The patient’s history does not state whether the manic episode persisted
for one week, which means it does not meet the criteria for diagnosing bipolar disorder. The
history only says that the mania was sustained for several days. Further exploration of this aspect
would be required to ascertain precisely how long the manic episode lasted; if it persisted for
seven days, this meets the criteria for diagnosing bipolar disorder, whereas if it did not last for a
week, it is not significant.
The expected future course of illness for this patient
The patient has a generalized anxiety disorder. The expected future course of the illness
is contingent on whether it is appropriately managed or not. If managed, the patient’s mood will
stabilize while his anxiety diminishes over time. The patient could function normally and lead a
balanced, productive, and meaningful life (ADAA, n.d.). However, if not managed, it could
precipitate a plethora of associated complications ranging from headaches and migraines, chronic
NW_10/17/20
pain, heart complications, or bowel complications (van Beljouw et al., 2010). The depression
could also worsen and may drive the patient into suicide.
Treating subsequent episodes of depression
If the patient developed a subsequent episode of depression, I would treat it with a
different category of antidepressant-TCAs, MAOIs, such as Phenelzine Sulfate, or Moclobemide
or an atypical antidepressant. TCAs cause more adverse effects than SSRIs and are unsuitable for
this patient. I could also use a non-SSRI antidepressant such as amitriptyline, imipramine, and
trimipramine. Adding a non-pharmacological therapy, such as cognitive-behavioral therapy,
could also be beneficial for the management of symptoms.
Choice of medication and mechanism of action
The drug of choice would be amitriptyline hydrochloride, Elavil. Amitriptyline is a TCA,
while TCAs are not commonly prescribed due to the severity of their side effects (Drug Bank,
n.d.). However, since SSRIs, the first line of medication for depression, was ineffective, TCAs
are a viable alternative. While the mechanism of action (MOA) of amitriptyline has not been
fully explained, the most feasible explanation is that the drug hinders the functionality of the
membrane pump (Drug Bank, n.d.). The membrane pump facilitates the reuptake of transmitter
amines, including norepinephrine and serotonin (Drug Bank, n.d.). Transmitter amines are
critical in modulating mood. Blocking the reuptake of these amines results in their concentration
in the synaptic cleft in the brain. Since these neurotransmitter amines are responsible for
depressive effects, lowering their concentration in the brain effectively improves mood stability
and diminishes depressive symptoms.
NW_10/17/20
References
Amitriptyline. (n.d.). DrugBank Online | Database for Drug and Drug Target
Info. https://go.drugbank.com/drugs/DB00321
Van Beljouw, I. M., Verhaak, P. F., Cuijpers, P., Van Marwijk, H. W., & Penninx, B. W.
(2010). The course of untreated anxiety and depression, and determinants of poor oneyear outcome: A one-year cohort study. BMC
Psychiatry, 10(1). https://doi.org/10.1186/1471-244x-10-86
Zimmerman, M., Balling, C., Chelminski, I., & Dalrymple, K. (2019). Patients with borderline
personality disorder and bipolar disorder (Borderpolar): A descriptive and comparative
study. Psychological Medicine, 112. https://doi.org/10.26226/morressier.5d1a038357558b317a140cf8
NW_10/17/20
1
DEMOGRAPHICS
Patient Initials:
Miss Chen
Age:
45 years
Sex:
Female
Race/Ethnicity:
Asian
SUBJECTIVE
CHIEF COMPLAINT (CC):
Cough
HISTORY OF PRESENT ILLNESS (HPI):
Coughing for the past one week, more severe at night. She is
currently taking decongestant, and ip prophine twice a day.
PAST HISTORY
PMH:
Had suffered a mild asthma three times while was a kid
PSH:
N/A
PSYCHIATRIC HISTORY:
Had never experienced any kind of psychiatric
FAMILY HISTORY / SOCIAL HISTORY
FAMILY HISTORY (FH):
The grandmother had suffered tuberculosis
SOCIAL HISTORY:
Her family and co-workers are very much okay, or fine.
MEDICATION RECONCILLIATION / REVIEW
MEDICATIONS & INDICATIONS:
Fluoroquinolones, macrolides and β-lactams
(Prescribed & OTC)
ALLERGIES / IMMUNIZATIONS
ALLERGIES:
IMMUNIZATIONS:
N/A
HEALTH PROMOTION / HEALTH MAINTENANCE
NUTRITION / DIET:
EXERCISE REGIMEN:
TOBACCO/ALCOHOL/
The patient should take a diet rich in protein. That is beneficial
for her health because it assists in the healing process. Foods like
nuts, seeds, beans, white meat and cold-water fishes like salmon
and sardines have anti-inflammatory properties.
Despite the need for more rest, the patient needs to engage in
a deep breathing exercise to assist her heal gradually
2
ILLICIT DRUG USE:
The patient should avoid tobacco, alcohol, and other illicit drugs
since they are irritants that may make her condition more
severe.
SAFETY MEASURES:
Wash the hands often, and also, cough or sneeze into a tissue
and throw it away.
The patient is screened using lightened device to check her
throat, mouth, and ears.
SCREENINGS / EXAMS:
REVIEW OF SYSTEMS
CONSTITUTIONAL / GENERAL:
Use a lighted instrument to check the throat, the ears, nasal
cavities, and the eye
EYES:
Okay
EARS/NOSE/MOUTH/THROAT:
No abnormality except the throat which looks a little red
CARDIOVASCULAR:
RESPIRATORY:
Mildly elevated respiratory and a productive Cough
GASTROINTESTINAL/ABDOMEN:
N/A
GENITOURINARY:
N/A
MUSCULOSKELETAL:
N/A
INTEGUMENTARY:
Running nose, and Sour throat
NEUROLOGICAL:
Difficulty in sleeping at night, mild shortness of breath, and
fever
PSYCHIATRIC:
N/A
ENDOCRINE:
Running nose, and Sour throat
HEMATOLOGIC / LYMPHATIC:
ALLERGIC / IMMUNOLOGIC:
OBJECTIVE
VITAL SIGNS:
T:
101.5
HR:
100
BP:
130/88
mm/Hg RR: 22
O2:
3
Height: N/A
Weight: No change in body weight
BMI: N/A
PHYSICAL EXAM
CONSTITUTIONAL / GENERAL:
The physical examination was done using a lighted instrument to check
the patient’ temperature, blood pressure, respiratory rate. Some of the
important regions covered include head and neck, heart and lungs,
extremities.
EYES:
N/A
EARS/NOSE/MOUTH/THROAT:
Ears are fine but throat looks a little red but they are okay
NECK:
The neck is normal
RESPIRATORY:
Mildly elevated respiratory and temperature
CARDIOVASCULAR:
Heart beat is abnormal.
CHEST / THORAX (BREASTS):
Lung’s findings are variable, there are some changes in the left lower lung
GASTROINESTINAL /
ABDOMEN:
Abdomen is normal
GENITOURINARY:
N/A
LYMPHATIC:
Her lymph nodes are okay without any swelling
MUSCULOSKELETAL:
N/A
INTEGUMENTARY / SKIN:
N/A
NEUROLOGIC:
N/A
PSYCHIATRIC:
N/A
RESULTS REVIEW
ASSESSMENT
DIAGNOSIS (Dx)
Community-acquired pneumonia
DIFFERENTIAL DIAGNOSES
Atypical community-acquired pneumonia, bronchitis, pulmonary tuberculosis, and lung cancer
4
PLAN
DIAGNOSTIC WORKUP
O2 Saturation, Chest x-ray, CBCd and metabolic profile, Sputum
culture and gram stain, and blood cultures.
PHARMACOLOGICAL
TREATMENTS:
Ceftriaxone (1 to 2 g IV daily), Cefotaxime (1 to 2 g IV every 8 hours),
Ceftaroline (600 mg IV every 12 hours), Ertapenem (1 g IV daily), and
a macrolide (azithromycin [500 mg IV or orally daily].
NON-PHARMACOLOGICAL
TREATMENTS:
Avoiding intubation or re-intubation whenever possible; head of bed
elevation; hand hygiene; shortening ventilation through sedation
interruptions, spontaneous breathing trials, or thromboembolic
prophylaxis.
REFERRALS:
If the symptoms get severe or are persistent, then there is need for her
to see the doctor once again for necessary checkup. Her temperature is
very high at 101.5, the respiratory rate is also abnormal, at 22.
EDUCATION:
She needs to take a deep breath and cough several times each hour to
loosen up mucus and get it out of her lungs. She also needs to wash her
hands with soap and water or alcohol-based hand rub after blowing the
nose or using the bathroom, and before eating.
Follow-up
A follow-up visit is necessary after one week to confirm that the
pneumonia has resolved
What would you do differently: I would carry out a laboratory test on the patient to determine
other possible diagnosis differentiation.
