Psychiatrists use a psychiatric evaluation to diagnose behavioral, developmental, emotional, and problems among children/adolescents. In addition, psychiatric evaluation is crucial in collecting data on the onset of specific clinical manifestations, duration, frequency, and intensity of presented symptoms of psychiatric diagnoses (Srinath et al., 2019). Consequently, This paper establishes notes from a comprehensive psychiatric interview of a friend – TP (Initial Psychiatric Interview/SOAP Note).
Initial Psychiatric Interview/SOAP Note
|Informed Consent||Both verbal and written consent were obtained based on the information given to the patient concerning the interview process. Furthermore, the patient understood the risks and benefits associated with a psychiatric evaluation. In addition, the patient demonstrated the ability to understand, integrate, and respond to the psychiatric questions (Initial Psychiatric Interview/SOAP Note).|
|Subjective||Verify Patient Name: TP DOB: 20/05/1997 Demographic: African American Gender Identifier Note: Female CC: The patient reports mild headaches, social withdrawal, and dramatic mood shifts. HPI: The patient reports mild headaches, social withdrawal, and dramatic mood shifts since she was a child. These symptoms increase in the presence of people, e.g., group work or weekend outs. Further, the patient also reports insomnia and a persistent feeling of dizziness. Consequently, He manages the pain through ibuprofen. The patient rates the pain at 2/10 with medication and 5/10 without medication. Pertinent history in the record and from the patient: Moreover, the patient presents no significant medical history. During assessment: The patient describes their mood as irritable, and her anger has worsened with time (Initial Psychiatric Interview/SOAP Note). |
Consequently, Patient self-esteem appears appropriate—no feelings of helplessness. However, he reports sleeplessness, a change in appetite, and tiredness(Initial Psychiatric Interview/SOAP Note).
The patient reports a lack of activity, irritability, exhaustion, excessive fears, and worries. However, the patient’s speech pattern and concentration capacity appear normal. No reported hallucinations, delusions, or obsessions. The patient reports daydreaming. The patient is alert and oriented × 3. Moreover, the patient has dressed appropriately for the occasion and time. No reported symptoms of eating disorder or characterological nature(Initial Psychiatric Interview/SOAP Note).
The patient does not report weight loss or gains. SI/ HI/ AV: The patient denies being suicidal homicidal, violent, or harboring inappropriate behavior. Allergies: Consequently, No Known Food and Drug Allergies. Past Medical Hx: Medical history: Hospitalized severally for the common cold as a child. Denies diagnosis of respiratory, cardiac, neurological, immune system, or endocrine conditions. No history of surgery or chronic infection. Past Psychiatric Hx: Previous psychiatric diagnoses: The patient denies a history of depression or anxiety. Previous medication trials: No medical trial participated. Safety concerns: History of Violence to Self: Reports jumping from the bed to enhance body energy spraining her toe in the process. History of Violence to Others: Denies being violent to others. Auditory Hallucinations: Reports paracusia (Initial Psychiatric Interview/SOAP Note).
Visual Hallucinations: Denies visual hallucinations. Mental health treatment history discussed: History of outpatient treatment: Outpatient treatment for a common cold as a child. Previous psychiatric hospitalizations: No record or mention. Prior substance abuse treatment: No record or mention. Trauma history: The patient denies traumatic history. Substance Use: The patient denies consumption of alcohol or nicotine products. Denies abuse of ETOH and other illegal substances. Current Medications: Ibuprofen 400mg orally every six hours for joint pain. Past Psych Med Trials: None reported Family Medical Hx: Father diagnosed with diabetes – managed through medication. The mother and siblings are alive and well. Family Psychiatric Hx: Substance use: Both parents and elder brother consume alcohol regularly.(Initial Psychiatric Interview/SOAP Note)
Suicides: None reported. Psychiatric diagnoses/hospitalization: Younger sister diagnosed with ADHD– is managed through medication. Developmental diagnoses: None reported. Social History: Occupational History: Currently and has always been a librarian. Military Service History: Denies previous military history. Education history: Graduated with a Bachelor of library and information science(Initial Psychiatric Interview/SOAP Note).
Developmental History: Had normal childhood development Legal History: No reported legal action. Live with the parents. Spiritual/Cultural Considerations: Christian. ROS: Constitutional: Reports no fever or weight loss(Initial Psychiatric Interview/SOAP Note).
Reports dizziness. Eyes: No eye pain or vision changes. ENT: Hearing is intact. Cardiac: No chest pain, breathing difficulty, or edema, Respiratory: No shortness of breath, cough, or wheezing GI: No abdominal pain. GU: No reports of painful urination or blood in the urine. Musculoskeletal: No joint pain or swelling. Skin: Normal skin turgor and moisture. Neurologic: Denies history of numbness or seizures. Reports general body weakness. Endocrine: No reports of excessive urination or extreme thirstiness. Hematologic: No blood clots, easy bruising, or bleeding. Allergy: No Known Drug and Food allergy. Reproductive: No significant issues were reported. Denies pregnancies, abortions, miscarriages, or hysterectomies (Initial Psychiatric Interview/SOAP Note).
|Verify the patient’s name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, and Photo. Include demographics, chief complaint, subjective information from the patient, names, and relations of others present in the interview. HPI: , Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative except…”|
|Objective||Vital Signs: Stable Temp: 98.9 F BP: 121/80 HR: 73 R: 16 O2: 93 Pain: 7/10 Ht: 5’7’’ Wt: 125lbs BMI: 19.6 LABS: Lab findings: WNL Tox screen: Negative Alcohol: Negative HCG: Negative Physical Exam: MSE: The patient appears anxious and tired but is compliant and well-acquainted. The patient is alert and oriented ×4. The patient is well dressed for the age, occasion, and time. However, the patient’s psychomotor activity is below normal. The patient maintains appropriate eye contact, a dysthymic effect, with a reported mood of irritability/anger. Speech: Slow speech, low tone, and difficulty in expressing herself. TC: Denies suicide or homicidal ideation. Coherent process and intact cognition. Short attention and concentration span yet knowledgeable. Judgment and insight appear normal. The patient can communicate personal needs and is motivated to comply and adhere to clinical intervention. The patient is willing to participate in the proposed treatment regimen and observe discharge instructions (Initial Psychiatric Interview/SOAP Note).|
|This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, and test results, and MSE, risk assessment, and psychiatric screening measure results. (Initial Psychiatric Interview/SOAP Note)|
|Assessment||DSM5 Diagnosis: Dx: Social anxiety disorder/Social Phobia. Coded as 300.23 (F40.10). This is the primary diagnosis. DSM5 criteria for Social Phobia as presented by the patient include(APA, 2013): Non-effective social communication Excessive anxiety and fear or Excessive distress about social interactions. Dx: Agoraphobia. Coded as 300.22 (F40.00). This diagnosis is refuted Initial Psychiatric Interview/SOAP Note. |
The DSM5 criteria for Agoraphobia include (APA, 2013): Fear and avoid social situations Incapacitation Panic-like symptoms Dx: Generalized anxiety disorder. Coded as 300.02 (F41.1). This diagnosis is refuted. The DSM5 criteria for Generalized Anxiety Disorder include (APA, 2013): Excessive worries about social interactions. An excessive concern for other’s evaluation. The patient can respond to the psychiatric intervention. This is crucial for establishing clinical consensus with the patient (Angell & Bolden, 2015). In addition, the patient understands the need for medication and is willing to uphold adherence (Initial Psychiatric Interview).
|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. Informed Consent (Ability Initial Psychiatric Interview/SOAP Note)|
|Plan (Note some items may only be applicable in the inpatient environment) (Initial Psychiatric Interview/SOAP Note)||Safety Risk/Plan: The patient is stable and is not in danger to herself and others. The patient denies any inappropriate ideation and appears cooperative to clinical interventions. Pharmacologic interventions: Maintain the current medication and dosage.Introduce Sertraline 50mg/day initially with a possibility of titration. Sertraline is considered an appropriate first-line pharmacological intervention for anxiety disorders (Bandelow et al., 2017)Refer the patient to a psychotherapist for a CBT. CBT is crucial in managing social anxiety among patients (Early & Grady, 2017). Education, including health promotion, maintenance, and psychosocial needs (Kennerley et al., 2017): Importance of mental health. Negative thoughts and their dangers. Alcohol and tobacco use. Attend social gatherings sparingly. Referrals: Psychotherapist for CBT. The patient is to return to the clinic after six weeks and attend CBT therapy weekly. Time spent in Psychotherapy: 30 minutes The visit lasted 45 minutes Date: 15/6/2021 Time: 1400hrs (Initial Psychiatric Interview).|
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Inc.
Angell, B., & Bolden, G. B. (2015). Justifying medication decisions in mental health care: Psychiatrists’ accounts for treatment recommendations. Social Science & Medicine, 138, 44-56. 10.1016/j.socscimed.2015.04.029
Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93. 10.31887/DCNS.2017.19.2/bbandelow
Early, B. P., & Grady, M. D. (2016). Embracing the Contribution of Both Behavioral and Cognitive Theories to Cognitive Behavioral Therapy: Maximizing the Richness. Clinical Social Work Journal, 45(1), 39-48. 10.1007/s10615-016-0590-5
Kennerley, H., Kirk, J., & Westbrook, D. (2017). An introduction to cognitive behavior therapy – Skills and applications (3rd ed.). London, England: Sage Publications
Srinath, S., Jacob, P., Sharma, E., & Gautam, A. (2019). Clinical practice guidelines for the assessment of children and adolescents. Indian journal of psychiatry, 61(Suppl 2), 158. 10.4103/psychiatry.IndianJPsychiatry58018