670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example

670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example

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. (670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)

CriteriaClinical Notes
Subjectivechief complaint- Patient x says he seeks consultation because he has legal issues regarding drinking and driving that he thinks were likely fueled by his psychiatric symptoms.. The college graduate is currently euthymic has never had suicidal ideation but some of the depressive episodes have incapacitated and interfered with both school and work.  HPI- Just before the manic episodes a few months ago he was put on a selective serotonin reuptake inhibitor (SSRI) for SAD symptoms as well as depression. Within days of initiation of SSRI medication he experience elevated mood. In addition to having episodes of low self- esteem, rejection sensitive and guilt ridden for no reason he reports social anxiety symptoms and is often nervous around new people and acquaintances. Due to anticipatory anxiety experiences will opts to avoid certain social events as the symptoms are manifest independent of his affective state. The SSRI medication made him lose anxiety, fear and avoidance. He reports that the mood elevation abated after SSRI cessation.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example) Past Medical and Psychiatric History- The patient though currently euthymic has a history of major depressive episodes most of which were untreated since his adolescence. He is not under any medication currently  has no family history of BD but the mother has generalized anxiety disorder(GAD).The symptoms have varied in severity and length manifesting as insomnia, depressed mood, and low interest in activities, poor energy and despondent thoughts. Social History- Upon graduation, the 26 year old reports having a few friends and very supportive family. He wants to be a news reporter(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)
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.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)
Objective                 Labs, test results- A thyroid function test to measure the patient’s thyroid gland functions. This would help rule out hypothyroidism another cause for depressive symptoms. Conduct a mental health evaluation and mood charting.  Vitals-98.8, 160/80, 76, 18, 5’10”, and 190 lbs  Review of Systems (ROS) – Patient reports mood swings from low self- esteem to guilt ridden and fear of rejection for no apparent reason. He is also affirmative of insomnia, increased energy and elevated moods when on SSRIs. Other manic symptoms were Patient denies suicidal ideation, grandiosity exhibition, felt he was invincible and that he was above the law. These feelings made him pick a quarrel with a man in a bar, drive under the influence and challenge authority when the police intervened.  Psychiatric screening measure resultsThe psychiatric screening results report normal function of thyroid gland.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)
This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)
AssessmentFindings- normal thyroid gland functioning established and mood charting indicative of episodes of mania and depressive episodes.  Diagnosis- Most likely diagnosis is BD due to the presence of mood swings.  differentials – Intermittent explosive disorder unlikely because the patient does not report experiencing episodes of unwarranted anger Depression ruled out because of absence of suicidal thoughts, attempts or plans although decreased energy, low self-esteem and guilt ridden are present. -(DSM-5  along with ICD-10 codes- The patient is in Bipolar II disorder since the BD does not interrupt the patient’s ability to function.  Treatment options- Whether depressive, dysthymic, and mixed states constitute the majority of BD illness burden. The patient is put on regimen of antidepressants, mood stabilizers like carbamazepine for short term and lamotrigine and second generation antipsychotics. The patient’s input is to engage in non-pharmacological interventions like psychotherapy. The obstacles to treatment includes failure of the patient to adhere to the prescribed medication and his lack of knowledge on management and treatment options for BD..  (670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)
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.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)
PlanContinue Lamotrigine at 10 mg dose. If no further improvement is noted in the next 30 days, the provider will consider increasing the dose to 20mg. The medication will be reinforced with continued outpatient counselling. Follow up is set in four weeks or earlier if any depressive episodes gets worse.  (670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)                       
Include a specific plan, including medications & dosing & 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.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)

PRESCRIPTION (for student use-Not VALID)

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Herzing Medical Clinic

          15 Medical Clinic Circle

Destination, SS, 00123

Phone: 123 456 7890

Fax: 123 456 7890

PMHNP Student Jane Herzing, APRN

License # SS 17245A

NPI # 1234567899

(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)
670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example 1

PATIENT DETAILS:                                               DATE:

NAME

………………Patient Doe……………………………………………………………..…..

DOB …….………………………………………………………..

ADDRESS

……………3515 Admiral Way……………………………………………………………

…………….Destination, SS   00123……………………………………………………..

(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)
670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example 2

___________________

Prescriber’s signature

Copy any Case study questions from the instructions and answer here.

  1. Does the patient’s history support a diagnosis of bipolar disorder even though his symptoms appear to have been triggered by a selective serotonin reuptake inhibitor?

Yes, the patient’s history supports a bipolar diagnosis even before his manic symptoms became ‘full blown’ after he was put on SSRIs. Mental health experts admit that diagnosis bipolar disorder is not an easy task there aren’t lab tests to make a confirmatory diagnosis and its correct diagnosis has to rely on a combination of methods. Prior to being put on the SSRIs, the 26 year man was having depressive episodes impaired cognition, despondent thoughts, depressed mood and poor energy among others. For the bipolar disorder before diagnosis to have become manifest- the mania phase may have presented itself as recovery from the depression phase.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)

This diagnosis for bipolar disorder is made after ruling out other conditions where a thyroid function test is needed to rule out hypothyroidism. To diagnose bipolar disorder the patient must have at least one depression episode and one manic or hypomanic episode after a mental health evaluation.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)

  • What would be the expected future course of illness for this patient?
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Researchers in mental health have found evidence indicating that almost 50% of all Bipolar disorder diagnosed cases outgrow the condition between the ages of 18 and 25 years. However, since patient is already 26 years old one can expect the future course of the illness for the young man is the manic- depression phases will continue to cause severe and unusual mood shifts and energy that significantly impact on the patient’s to execute his daily tasks. Be that as it may, ongoing treatment and self-management can see the patient maintain stable moods for long periods of time.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)

  • If the patient develops another depressive episode, how would you treat it?

To treat another depressive episode, I would use lamotrigine as it reduces the risk of depressive episodes recurrences on a long term basis.

  • What medication would you choose (there could be many correct answers).

FDA has approved Lamotrigine for long term prophylaxis in BD. Other medications that could be used is lithium or even second generation antipsychotics like quetiapine, lurasidone, olanzapine – fluoxetine and cariprazine for short term treatment of BD acute depressive episodes. Taking Lamotrigine, despite its mechanism of action being not adequately understood, it belongs to the triazine group meaning that it selectively binds sodium channels. The binding then stabilizes the presynaptic neuronal membrane and therefore inhibits the release of glutamate. Lamotrigine is also believed to impact other neurotransmitters like dopamine, serotonin and norepinephrine. Another theory contends that Lamotrigine has the capacity to interact with voltage activated calcium gated channels triggering a wide range of activity.(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)

  • Provide and reference a recent research article (Published over the last 3 years) on the  medication treatment of Mood Disorders
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Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: a major unsolved challenge. International journal of bipolar disorders8(1), 1-13(670 Case Study Psychiatric SOAP Note Template with Rx Comprehensive nursing paper example)

Reference

National Center for Biotechnology Information (nih.gov)

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