SOAP PP
Domo0220
ComprehensivePsychiatricAssessment_Week4.docx
Comprehensive Psychiatric Evaluation Template
With Psychotherapy Note
Encounter date: ____20/07/2023__________________
Patient Initials: __R.W.____ Gender: M/F/Transgender __Female__ Age: __66___ Race: African-American__ Ethnicity: __Black__
Reason for Seeking Health Care: “I do not know what is happening to me. I have been having trouble falling asleep, and when I do, I cannot seem to stay asleep. It is frustrating because I have never had any issues with sleep, but recently I have been spending the better part of my night tossing and turning in bed."
HPI: The patient is a 66-year-old female with a history of type 2 diabetes mellitus and hypertension who comes to the clinic with complaints of difficulty falling asleep. She admitted that she started experiencing these symptoms two months ago, and they have been getting worse with time. She admitted that she used to get plenty of sleep each night for 8–10 hours, but for two months ago, the number of hours she slept has significantly declined to a maximum of 3 hours. She admitted that she spends most of her night tossing and turning, and when she does get to sleep, she wakes shortly after. She admitted that this lack of sleep leaves her feeling fatigued during the day and with low energy. She admitted that the lack of sufficient sleep has greatly impacted her daily life, as she feels too tired to perform her daily activities. She admitted to experiencing headaches, which she attributed to a lack of sufficient sleep. She admitted that she has been under a lot of stress in her life as a result of her son being diagnosed with lung cancer months ago. She admits that taking a warm bath before bedtime helps her sleep temporarily, but she awakens after a short while. She rates the severity of her overall symptoms at 7/10 due to their negative impact on her life. She admitted to always taking a cup of coffee in the evening for two years. The patient admitted to taking Metformin 500 mg once a day in the evening as part of her ongoing treatment for T2DM. She admitted to also taking losartan 50 mg once a day in the morning, and the treatment is ongoing for hypertension. She denied fever, chills, coughing, nausea, or vomiting.
SI/HI: She denied a history of suicidal attempts or ideations
Sleep: She admitted to never having trouble sleeping until two months ago. She admitted to having trouble falling asleep and staying asleep. Appetite: She denied any changes in appetite or weight.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient admitted to being allergic to bee stings, which result in moderate allergic reaction of localized swelling, pain, and redness at the sting area. She denied any known drug, food, latex, or herbal allergy. Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
|
None
|
None |
None |
None |
|
None |
None |
None |
None |
Outpatient psychiatric treatment:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
Detox/Inpatient substance treatment:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
History of suicide attempts and/or self injurious behaviors: ____________________________________
Past Medical History
· Major/Chronic Illnesses ___The patient admitted to being diagnosed with hypertension when she was 30 years old and type 2 diabetes mellitus when she was 40 years old. She admitted that both conditions are currently active.
· Trauma/Injury_ She admitted to occasional falls and injuries that caused minor bruises.
· Hospitalizations_ She denied any history of hospitalization
Past Surgical History She admitted to having her wisdom teeth removed due to crowding, which caused the alignment of the existing teeth and bite difficulties.
Current psychotropic medications:
_______________________None__________________ ________________________________
_________________________________________ ________________________________
Current prescription medications:
Metformin 500 mg once a day in the evening and losartan 50 mg once a day in the morning, as part of her ongoing treatment for T2DM and hypertension respectively. _______________________________
_________________________________________ ________________________________
_________________________________________ ________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
______________None___________________________ ________________________________
_________________________________________ ________________________________
Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)
|
Substance |
Amount |
Frequency |
Length of Use |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
|
None |
None |
None |
None |
Family Psychiatric History:
· The patient admitted that her father who died when he was 68 years old had a history of generalized anxiety disorder which he managed with medication and psychotherapy.
· The patient admitted that her mother who died when she was 72 years old had a history of obsessive-compulsive disorder. She managed this condition with both medication and psychotherapy.
· The patient admitted that her elder sister who is 72 years old has a history of obsessive-compulsive disorder and generalized anxiety disorder which she strictly manages with both medication and psychotherapy whenever recommended.
· The patient’s elder son, who is currently 35 years old, has a history of generalized anxiety disorder, which he manages with medication and psychotherapy. He has currently been diagnosed with Stage IA lung cancer.
Social History
Lives: Single-family House/Condo/ with stairs: ______ 6-bedroom family house____ Marital Status: _Married__
Education: _ Bachelor of Science in Midwifery
Employment Status: Employed__ Current/Previous occupation type: _Midwife at the Jackson Memorial Hospital_
Exposure to: _Denies__ Smoke_ Denies___ ETOH __Denies__ Recreational Drug Use: Denies
Sexual Orientation: ___Heterosexual___ Sexual Activity: _Active___ Contraception Use: _________None___
Family Composition: Family/Mother/Father/Alone : The patient admitted that both her parents are not alive. Her brother and sister live in different states. She lives with her husband and two dogs.
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): _____The patient admitted that she was born in Kenya, Africa, but her parents relocated to the United States when she was three years old. The patient admitted to having had a happy childhood and was often up to mischief. She denied being involved in any criminal or illegal activities during her lifetime. She admitted that she lives in a six-bedroom family house with her husband and two pet dogs. She admitted that she enjoys painting and playing tennis whenever she gets the chance. She admitted to being a people person and having a large group of friends. She denied a history of abuse, trauma, or violence. She admitted to only being married once and is still married after 30 years.
Health Maintenance
Screening Tests
· The patient received the Beck Depression Inventory (BDI) screening on November 23, 2020, and her score was 4, which was negative for any significant depression symptoms.
· The patient received the GAD-7 screening test on November 23, 2020, and her score was 2, indicating minimal anxiety levels.
· The patient received her annual checkup on the 4th of January, and the results were negative for any abnormalities.
· The patient received a pure tone audiometry test to evaluate her hearing. The results showed mild sensorineural hearing loss, a common factor in older adults.
Exposures: She denies being exposed to any harmful substances currently.
Immunization HX:
The patient admitted that she is current on all age-related immunizations, including the flu vaccine pneumococcal vaccine, shingles vaccine, and the COVID-19 booster vaccine
Review of Systems (at least 3 areas per system):
General: The patient admitted to having problems with falling asleep or staying asleep.
She admitted to feeling fatigued during the day and having low energy levels. She denied weight gain, or loss, or experiencing any chronic pain.
HEENT: She admitted to constant headaches, admitted to hail loss, denies recent or past head injuries.
She denied any recent or past eye disorders, double vision, or eye redness. She admitted to mild sensorineural hearing loss, denies recent ear infections, or ear injuries. She denies nasal discharge, postnasal drip, bleeding or congested nose. She denied sores in or around the mouth, she denied decayed or broken teeth. She denied five missing teeth including her wisdom teeth.
She denied any changes in her voice, hoarseness, sore throat, or trouble chewing or swallowing.
Neck: The patient denies any neck pain, stiffness, or difficulty moving the neck.
Lungs: The patient denies any respiratory symptoms such as cough, shortness of breath, or wheezing.
Cardiovascular: The patient denies any cardiovascular symptoms like chest pain, palpitations, or edema.
Breast: She denied any changes in breast size, masses, nipple discharge, or pain.
Admitted to occasional self-breast examination.
GI: She denied a history of ulcers, hepatitis, inflammatory bowel disease. She admitted to occasional heartburn, bloating, and stomach aches. She denied nausea, vomiting, constipation or diarrhea.
Male/female genital: She denied noticing any rashes, lesions, sores, or foul-smelling abnormal discharge.
GU: She denied frequent urination at night,
denies burning feelings on urination, an increased need to urinate shortly after urination. Admits to occasional urine leakage.
Neuro: Admits to constant headaches. Denies issues with coordination numbness, tingling, blackout spells.
Musculoskeletal: She denies any joint injury, pain, swelling, muscle spasms, or restrictions.
Activity & Exercise: She admits to walking for 2 miles three times a week. Admits that she likes to paint and play tennis at least 4 times a week.
Psychosocial: The patient admitted to having trouble sleeping or falling asleep. Admits to being under a lot of stress. Denies hallucinations, paranoia, or suicidal ideations.
Derm: The patient denies any changes in skin color, moles, lesions, or rashes.
Nutrition: The patient admitted to taking a balanced diet every 6 times a week and eating first foods once a week. She admitted to drinking a lot of water and taking a cup of coffee every evening.
Sleep/Rest: She admitted that for the past two months she has been finding it challenging to fall asleep or stay asleep. She admitted she gets at most 4 hours of sleep. She admitted to being exhausted during the day as a result of lack of sleep.
LMP: She admitted that her last menstruation was 26 years ago. She admitted her menstruation cycle was regular occurring every 30 days accompanied by mild stomach cramps.
STI Hx: She denied a history of sexually transmitted infections. Admitted to several urinary tract infections over the years. Denied ever engaging in risky sexual behaviors.
Physical Exam
BP__130/80 mmHg measured when the patient was in a seated position______TPR_96.3F measured through the mouth____ HR: ___73__ RR: _18___Ht. _167.6 cm____ Wt. ___68 kg___ BMI ( percentile) __24,2 kg/m2 (Normal range) __
General: The patient appears fatigued but is well-groomed and appropriately dressed. She is able to hold eye contact and answer questions appropriately
HEENT: Proportioned cranium, without any indications of fractures, tenderness, or injury. No indication of intermittent instances of blurred vision or heightened sensitivity to light. Her auditory function is slightly affected, there are no signs of secretion or hemorrhaging in her ears. Her gum tissues exhibit a healthy pink appearance, and no dryness in both the mouth and tongue and no evidence of oral ulcers observed.
Neck: The patient's neck is supple, with no palpable masses or lymphadenopathy. No neck stiffness or tenderness noted.
Pulmonary: Clear breath sounds bilaterally. The patient denies any respiratory symptoms.
Cardiovascular: Heart sounds are regular with no murmurs, gallops, or rubs. Peripheral pulses are palpable and equal bilaterally.
Breast: The patient's breasts show no visible abnormalities or masses on visual inspection or palpation, breasts are symmetrical and exhibit typical signs of aging, such as wrinkly skin.no signs of redness, dimpling, or alterations in texture observed.
GI: The abdomen is soft and non-tender. Bowel sounds are present and normal. No organomegaly or masses palpable. the abdominal region appears supple and non-sensitive upon examination. Bowel sounds are perceptible and exhibit a regular pattern, indicative of their normal function. There are no notable signs of organ enlargement or any discernible masses detectable by palpation
GU: Presence of yellow but non-odorless urine without traces of blood. No reports of abnormal urinary frequency, urgency but positive report of occasional leakage.
Neuro: The patient is alert and oriented to person, place, and time. Cranial nerves 2-12 are intact, and no focal neurological deficits observed. Reflexes are within normal limits.
Musculoskeletal: The patient exhibits no joint abnormalities, swelling, or tenderness. Full range of motion in all extremities.
Derm: The patient's skin shows no visible abnormalities, rashes, lesions, bruises, or blisters. Skin is clean and dark-brown in color.
Psychosocial: The patient appears fatigued and slightly withdrawn, with signs of insomnia and mild frustration. No signs of psychosis or abnormal thought processes noted.
Misc.: No additional information collected
Mental Status Exam
Appearance: The patient appears neatly dressed and groomed. She appears her stated age and is appropriately dressed for the weather and occasion. She appears slightly fatigued and with low energy level
Behavior: The patient's behavior is cooperative and friendly throughout. She follows instructions appropriately and does not show any signs of agitation or restlessness.
Speech: The patient's speech is fluent, clear, and coherent. There are no signs of slurring, stuttering, or any other speech abnormalities. She maintains an average rate of speech and is responsive to questions.
Mood: The patient's mood appears to be euthymic. She does not report extreme emotions and admits to feeling generally stable and content.
Affect: The patient's affect is appropriate to the context of the conversation. She shows appropriate emotional responses when discussing various topics and does not show any flat or blunted affect.
Thought Content: The patient's thought content appears to be intact and there are no overt signs of delusions, hallucinations, or paranoid ideation.
Thought Process: The patient's thought process is logical and organized. She is able to maintain good flow of conversation and connects ideas in a rational manner.
Cognition/Intelligence: The patient's cognitive functions appear intact. She demonstrates good attention and concentration during the examination. She is able to recall past events and provide relevant details.
Clinical Insight: The patient demonstrates good clinical insight into her current state of health. She admits to challenges she may be facing and is open to discussing them.
Clinical Judgment: The patient's clinical judgment appears to be reasonable. She is capable of understanding the implications of her condition.
|
Psychotherapy Note According to the patient's clinical symptoms and history the most probable diagnosis is insomnia disorder. The patient should therefore receive cognitive behavioral therapy because it will help to address both the patient's cognitive and behavioral factors that are contributing to her sleep difficulties. |
|
Therapeutic Technique Used: Cognitive -Behavioral-Therapy |
|
Session Focus and Theme: The session focused on addressing the patient's insomnia symptoms by utilizing CBT techniques. The theme primarily focused on identifying and challenging negative thought patterns and behaviors related to sleep such as stress and drinking coffee before bedtime. |
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Intervention Strategies Implemented: During the therapy sessions the therapist made use of two intervention strategies to help the patient manage her insomnia symptoms.one strategy used was sleep education whereby the patient was educated on the importance of sleep hygiene and healthy sleep. Another technique used was relaxation techniques whereby the patient was taught relaxation exercises, such as progressive muscle relaxation and deep breathing exercises, to promote a peaceful sleep. |
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Evidence of Patient Response: The patient was open to learning new ways of managing her insomnia because she was tired of feeling fatigued and with low energy levels every day. “I want to be able to perform my daily activities without having my husband do most of the things for me because I am too tired to do anything. I don't want to feel like a burden and therefore I am ready to do and follow every instruction to ensure I manage these symptoms of insomnia. |
Plan:
Pittsburgh Sleep Quality Index (PSQI)
Pittsburgh Sleep Quality Index is a self-rated questionnaire which assesses sleep quality and disturbances over a 1-month time interval (Cheng et al., 2020). The patient's score of 6 indicates significant sleep disturbance.
Thyroid Function Tests:
TSH: 3.5 mIU/L (normal range)
FT4: 1.3 ng/dL (normal range)
FT3: 2.9 pg/mL (normal range)
Differential Diagnoses
1.Insomnia disorder DSM-5 780.52 (G47.00)
2.Major depressive disorder 296.20 (F32.0)
Principal Diagnoses
1.Insomnia disorder DSM-5 780.52 (G47.00)
Insomnia disorder is a DSM-5 disorder that occurs as a result of a person experiencing
recurrent poor sleep quality or quantity (Bjorvatnet al., 2021) Insomnia disorder symptoms often result in significant impairment in important areas of functioning. Insomnia is typically diagnosed through conducting a medical history, physical examination, and diagnostic tests (Xiang et al., 2021).
Treatment Plan
Zolpidem is a sedative-hypnotic of the imidazopyridine class, and is typically a fast choice medication for the treatment of insomnia due to its rapid onset a short duration of action with no significant residual sedation in the morning (McCall et al., 2019). The patient was therefore prescribed zolpidem 5 mg taken orally, once a day before bedtime. The patient was educated on the side effects of zolpidem as it can cause drowsiness, dizziness, and impaired coordination and she should therefore avoid engaging in activities that require mental alertness, such as driving. The cost for zolpidem oral tablet 5 mg is around $11 for a supply of 14 tablets.
Plan:
Diagnosis #1 Insomnia Disorder
Diagnostic Testing/Screening: Pittsburgh Sleep Quality Index (PSQI)
Pharmacological Treatment:
Name: Zolpidem
Dosage: 5 mg
Route: Orally
Frequency: Once a day before bedtime
Estimated Cost: The cost for a zolpidem oral tablet 5 mg is around $11 for a supply of 14 tablets.
Non-Pharmacological Treatment: Cognitive -Behavioral-Therapy
Patient/Family Education:
1.Maintain a consistent sleep schedule.
2.Create a calming bedtime routine.
3.Limit daytime naps.
4.Avoid caffeine and stimulants close to bedtime.
5.Make your bedroom comfortable and sleep-conducive.
6.Use the bed only for sleep and intimacy .
Referrals: Psychotherapist
Follow-up: 2 weeks to assess effectiveness of medication.
Anticipatory Guidance:
1.Avoid electronic screens before bedtime.
2.Practice relaxation techniques, like deep breathing or meditation.
3.Get regular exercise, but not too close to bedtime.
4.Take medication exactly as prescribed.
5.Avoid heavy meals before bedtime.
6.Keep a sleep diary to track progress.
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
References
Bjorvatn, B., Jernelöv, S., & Pallesen, S. (2021). Insomnia–a heterogenic disorder often comorbid with psychological and somatic disorders and diseases: A narrative review with focus on diagnostic and treatment challenges. Frontiers in Psychology, 12, 63https://doi.org/10.3389/fpsyg.2021.6391989198.
Cheng, P., Cuellar, R., Johnson, D. A., Kalmbach, D. A., Joseph, C. L., Castelan, A. C., ... & Drake, C. L. (2020). Racial discrimination as a mediator of racial disparities in insomnia disorder. Sleep Health, 6(5), 543-549.https://doi.org/10.1016/j.sleh.2020.07.007
McCall, W. V., Benca, R. M., Rosenquist, P. B., Youssef, N. A., McCloud, L., Newman, J. C., ... & Krystal, A. D. (2019). Reducing suicidal ideation through insomnia treatment (REST-IT): A randomized clinical trial. American Journal of Psychiatry, 176(11), 957-965. https://doi.org/10.1176/appi.ajp.2019.19030267
Xiang, T., Cai, Y., Hong, Z., & Pan, J. (2021). Efficacy and safety of Zolpidem in the treatment of insomnia disorder for one month: A meta-analysis of a randomized controlled trial. Sleep Medicine, 87, 250-256. https://doi.org/10.1016/j.sleep.2021.09.005
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials)__________R.W.____________________ Age ___66_______
Date: ________20/07/2023_______
RX __________Zolpidem ____________________________
Dispense: _____14 tablets_____ Refill: ___0______________
No Substitution
Signature: ____________________________________________________________
Rev. 2272022 LM
