Unit 4-Adult Psychiatric Initial Interview-Assessment. Due 1-31-24. NU672 Counseling and Psychotherapy

Psychiatric SOAP Note Template

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. Refer to the Psychiatric SOAP Note PowerPoint for further detail about each of these sections.

Criteria Clinical Notes Subjective Patient Information: EH, 15-year-old, Caucasian female

CC: “I am concerned about my daughter’s weight loss and excessive

exercising.”

HPI: EH presents with her mother for evaluation related to concerns

pertaining to intentional weight loss that began a year ago, which she

now deems has become concerning. Mom reports EH has lost 30

pounds over the past 12 months, 20 pounds of which she has lost

during the last six months. EH admits to restricting her

caloric/carbohydrate intake, binging and purging, abusing laxatives,

and exercising three to four hours a day. Moreover, EH reports

anxiety related to her “supposed” weight issue and a desire to lose

five more pounds.

Current Medications: None at present time

Allergies: NKDA

Past Medical History

Metatarsal stress fracture (March 2019)

Childhood obesity

No hospitalizations

Surgical History: Unremarkable

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.

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Social History

Full-time high school student (straight A student)

Lives with mother

Denies alcohol and recreational drug use

Heterosexual, not sexually active at present time, not involved in a

relationship

Family History

Unremarkable psychiatric history other than cousin with eating

disorder Objective

ROS

ROS negative with the exception of:

Constitutional: 30-pound intentional weight loss/12 months, (+)

fatigue

Gastrointestinal: Denies abdominal pain, blood, or coffee ground

emesis (+) constipation

Genitourinary: Denies dysuria, frequency, or hematuria. LMP:

“maybe three months ago,” irregular menses, denies pregnancy, not

sexually active

Neurological: Fainted once during volleyball game, attributes to

heat. Denies headache, dizziness, ataxia, numbness or tingling in the

extremities

Psychiatric: Denies history of depression, anxiety, or eating disorder

EXAM

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.

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VS: weight 100 pounds, 5’ 7” BMI 15.7 temp, 95.9, pulse oximetry

99% (unable to figure out how to obtain remainder of VS)

Mouth: Cracked lips, mild angular stomatitis

Skin, hair, nails: Lanugo, dry, rough skin, abrasions and calluses on

dorsa of right hand

Cardiac: Orthostatic hypotension (I was not able to take vitals but

noted this finding in case study)

Gastrointestinal: Abd lean, non-distended, (+) BS x 4, non-tender, no

organomegaly

OBJECTIVE

VS: weight 100 pounds, 5’ 7” BMI 15.7 temp, 95.9, pulse oximetry

99% (unable to figure out how to obtain remainder of VS)

Mouth: Cracked lips, mild angular stomatitis

Skin, hair, nails: Lanugo, dry, rough skin, abrasions and calluses on

dorsa of right hand

Cardiac: Orthostatic hypotension (I was not able to take vitals but

noted this finding in case study)

Gastrointestinal: Abd lean, non-distended, (+) BS x 4, non-tender, no

organomegaly

MSE

Appearance: Thin, emaciated, young lady, dressed in loose attire.

Rough skin and thin hair. Abrasions and calluses are noted on the

dorsa of her right hand. Initially reserved but able to establish good

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rapport towards the end of examination.

Behavior/Activity: Fidgety throughout the consultation

Speech: Spontaneous, normal rate, tone, and flow

Thought form: Logical and goal directed

Thought content: Glorified ideas on her weight. Although she is

preoccupied with the fear of being overweight, she does not exhibit

an obsession. No hallucinations or delusions are noted.

Mood: Mild dysphonia

Affect: Reactive

Suicidal Ideation: None

Homicidal Ideation: None

Orientation: A/O x 3

Memory: Immediate, recent, and remote memory intact

Judgment/Insight: Poor, does not recognize weight loss to be a

problem but nonetheless she is willing to participate in treatment

Attention/Concentration: Intact

SCREEINGS

EAT-26 > 20 (positive for eating disorder evaluation)

HAM-D: Not resulted

DIAGNOSTICS

12 lead EKG: Borderline sinus bradycardia: Rate 60

T-wave flattening, ST depression, and QT prolongation

CMP: hypokalemia 3.2

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Phosphorus, magnesium, HCG, TSH, TFT: WNL

Assessment DIAGNOSIS

Anorexia nervosa, binge eating/purging type, F50.02

DSM-5 criteria for anorexia nervosa, binge eating/purging type

includes the following:

 restriction of energy intake relative to physiologic

requirements

 overwhelming fear of putting on weight or becoming

overweight, or persistent behavior that impedes weight gain,

although already at a significantly low weight

 body image perception disturbance or persistent lack of

awareness of the gravity of

actual low BMI

engagement in self-induced vomiting or laxative misuse over

previous three months (American Psychiatric Association,

2013).

Moreover, EH presented with the following clinical signs, which are

common to individuals suffering from anorexia nervosa:

 amenorrhea

 bradycardia (borderline)

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.

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 brittle nails and fine hair

 hypokalemia

 lanugo

significant weight loss (Harrington, Jimerson, Haxton, &

Jimerson, 2015).

OBSTACLE(S) TO TREATMENT

 Poor self-esteem

 Limited peer support system

 Poor judgment/insight, does not grasp gravity of current

situation as she continues to insist on losing five more

pounds.

Plan PLAN

APA criteria for inpatient admission for anorexia nervosa includes the

following:

 heart rate less than 50 beast/minute during the day and 45

beats/minute during the night

 systolic blood pressure less than 90

 orthostatic changes in pulse or blood pressure

 arrhythmia

 temperature less than 96 °F

 less than 75% ideal body weight or continued weight loss

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

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plan should relate directly to your Assessment.

regardless of intensive therapy

 refusal to eat

 outpatient treatment failure (Campbell & Peebles, 2014).

Although I was not able to fully calculate EH’s vital signs due to my

inexperience with the iHuman program, I feel that she eseentially

meets criteria to be admitted to the hospital based on her clinical

presentation and poor insight and judgement.

References

American Psychiatric Association. (2013). Diagnostic and statistical

manual of mental disorders (5th ed.). Washington, DC:

American Psychiatric Publishing.

Campbell, K., & Peebles, R. (2014, September). Eating disorders in

children and adolescents: States of the art review. Pediatrics,

134(3). Retrieved from

https://pediatrics.aappublications.org/content/134/3/582

Harrington, B. C., Jimerson, M., Haxton, C., & Jimerson, D. C.

(2015, January). Initial evaluation, diagnosis, and treatment of

anorexia nervosa and bulimia nervosa. American Family

Physician, 1(91), 46-52. Retrieved from

https://www.aafp.org/afp/2015/0101/p46.html

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