SOAP PP

Comprehensive Psychiatric Evaluation Template

With Psychotherapy Note

Encounter date: 08/28/2023

Patient Initials: P.S. Gender: M/F/Transgender Male Age:18 Race: Caucasian Ethnicity White

Reason for Seeking Health Care: _ “I have been feeling extremely anxious, and it's like my mind is constantly racing. I cannot help but worry over everything, even though I know my worries are irrational.”

HPI: The 18-year-old patient arrives at the clinic with his worried mother. The patient admitted that he first started experiencing mild symptoms of anxiety when he was 16 years old, but the anxiety did not interfere with his daily functioning. He admitted, however, that the symptoms intensified two months ago and have continuously worsened, especially now that he is planning to relocate to a new state. He admitted that he finds himself worrying over every aspect of his life, such as academics, relationships, finances, and more recently, the prospect of living in another state away from her family and friends and starting college. The patient admitted that he often feels restless, and finds it difficult to sit still. He admitted to feeling fatigued due to the constant state of anxiety and experiencing occasional headaches. He also finds it difficult to concentrate on anything due to the racing and intrusive thoughts. He also admits to being easily irritable and experiencing muscle tension, especially in the neck and shoulders. He admitted that stressful situations often worsen the symptoms, but admitted that engaging in physical activities such as intense workouts at the gym and painting often provides temporal relief. He admits that on a scale of 1–10, his symptoms severity is 7/10, as they have led to a decline in his academic performance and social relationships. He denied being under any medication.

SI/HI: He denied a history of suicidal or homicidal attempts

Sleep:  He admits that he finds it hard to fall asleep due to racing thoughts.

Appetite:  He denied any changes in his appetite or unintentional weight loss or gain.

Allergies (Drug/Food/Latex/Environmental/Herbal): He denied any known allergies to drugs, food, latex, the environment, or herbs. 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

History of suicide attempts and/or self-injurious behaviors: The patient denied having a history of suicidal attempts or engaging in self-injurious behaviors recently or in the past.

Past Medical History

· Major/Chronic Illnesses _ The patient denied being diagnosed with any major or chronic illness in the past or recently.

· Trauma/Injury _ He admitted to occasional minor injuries caused mostly falling off his bicycle.

· Hospitalizations: He denied a history of hospitalization.

Past Surgical History: He denied undergoing any surgical procedures recently or in the past.

Current psychotropic medications:   None

Current prescription medications:  None

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's 45-year-old mother is still alive. When she was 12 years old, she received an obsessive-compulsive disorder diagnosis. Since then, she has used medicine and treatment to control the illness.

· The patient's 47-year-old father is still alive. Generalized anxiety disorder and panic disorder were identified in him. He treats the ailments with medication and counseling.

· The patient's 23-year-old older brother is still alive. His attention-deficit/hyperactivity condition was identified. He uses medication and psychotherapy to treat the issue.

· The patient’s paternal grandfather died in a car accident when he was 68 years old. He was diagnosed with generalized anxiety disorder when he was 19 years old and managed the condition with medication and occasional psychotherapy.

Social History

Lives: Single family House/Condo/ with stairs: Currently living in a 5-bedroom family house Marital Status: Single

Education: Highschool

Employment Status: Unemployed Current/Previous occupation type: Student

Exposure to: Denies Smoke Denies: ETOH Denies: Recreational Drug Use: Denies.

Sexual Orientation: Heterosexual Sexual Activity: Not active Contraception Use: None

Family Composition: Family/Mother/Father/Alone : The patient currently lives with his mother, father, and older brother in a 5-bedroom family house.

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient was born in Miami, Florida, and is the last of two children. He admitted that he had a happy childhood and enjoyed playing with his childhood friends. He denied being involved in any illegal or criminal activities. He currently lives in a 5-bedroom family house with both parents and his older brother. He admitted he is soon set to relocate to a different state to live alone as he is going to college. He enjoys bicycle riding and painting. He also enjoys working out and goes to the gym every day after school for 2 hours. He denied a history of abuse, violence, or trauma. He admits to having had a large circle of friends but over the past two months he has isolated himself from his friends and social events due to his constant anxiety. He denied a history of being married.

Health Maintenance

Screening Tests (submit with SOAP note): Depression, Anxiety, ADHD, Autism, Psychosis, Dementia

· He admitted to having his annual checkup on January 21, 2023. The examination did not reveal any abnormalities.

· He admitted he goes for dental checkups twice a year, with the last checkup being on June 3, 2023. The results were negative for gingivitis, cavities, or any tooth disease.

· He admitted to always putting on protective gear, such as a helmet, whenever he rides his bicycle.

· He admitted to always putting on his seatbelt whenever he was in a vehicle.

Exposures: Denies any harmful exposure

Immunization HX: He admits to being up-to-date with all childhood developmental vaccinations. He is also current on the flu vaccination, the COVID 19 vaccination and booster.

Review of Systems (at least 3 areas per system):

General: The patient admits to feeling fatigued and lacking energy on most days due to his anxiety, headaches, muscle tension, restlessness, and difficulty falling asleep. He denies any recent weight changes, fevers, or chills.

HEENT: The patient admits to experiencing occasional headaches. He denies double vision, eye pain, or eye strain. He denies hearing difficulties or ringing in his ears. He admits to sinus congestion and post-nasal drip during high-anxiety periods. He denies gum disease, missing or broken teeth. He denied having trouble chewing, or swallowing

Neck: The patient denies any swelling, tenderness, or restrictions in his neck. He admits to occasionally feeling tension in his neck and shoulder muscles during times of heightened anxiety.

Lungs: Denied shortness of breath at rest but admits to experiencing shortness of breath during anxiety attacks. He denies coughing, wheezing, or chest pain.

Cardiovascular: The patient denies any history of heart palpitations, chest discomfort, or racing heart. He admits to feeling his heart race during episodes of severe anxiety. He denies any edema in his legs or extremities.

Breast: The patient denies any breast enlargement, tenderness, masses, or nipple discharge.

GI: The patient says he has experienced occasional stomach discomfort, especially during periods of extreme anxiety. He denies any significant changes in appetite, nausea, vomiting, or diarrhea.

Male/female genital: denied any pain, or swelling in his penis.

GU: The patient denies any urinary frequency, urgency, or pain while urinating. He denies any changes in urinary habits.

Neuro: The patient admits to having difficulty concentrating, especially when feeling anxious. He denies any seizures, tremors, or uncontrolled movements.

Musculoskeletal: The patient denies any joint pain, stiffness, or swelling. He admits to muscle tension, particularly in his shoulders and neck, during periods of extreme anxiety.

Activity & Exercise: The patient admits that he engages in rigorous physical activities to help distract him from his thoughts. He admits that he enjoys working out, riding his bicycle, and painting.

Psychosocial: The patient admits to feeling constant, extreme worry over every aspect of his life and being easily irritable. He admits to feeling socially isolated and avoiding social events due to his anxiety. He admits to changes in his relationship with his family and close friends.

Derm: The patient denies any skin changes, rashes, or itching. He admits that he occasionally picks at his skin as a nervous habit during moments of high anxiety.

Nutrition: No significant changes in his eating habits or unintentional weight loss. He admits to consuming 8 glasses of water every day.

Sleep/Rest: The patient admits to experiencing difficulty falling asleep due to racing thoughts and worries. He denies any nightmares or night sweats.

LMP: N/A

STI Hx: He denied a history of sexually transmitted infections.

Physical Exam

BP:120/87 mm/Hg TPR: 95.3F taken orally HR: 75 RR: 18 Ht. 5’7 Wt. 54 kg BMI ( percentile) ____18.6 kg/m2 (8%, Healthy weight) _

General: The patient appears well-nourished and in no acute distress. He is alert and oriented to person, place, and time. He is cooperative and engages in conversation appropriately. No visible signs of abnormal movements or tics. The patient appears restless and unable to sit still.

HEENT: Head: Normocephalic and atraumatic, hair is short, dark and evenly distributed, Eyes: Pupils are dark, equal, and sensitive to light, no signs of pupillary abnormalities. Extraocular movements are intact. Ears: Bilateral tympanic membranes are clear, no discharge or inflammation. Nose: Nasal passages patent, mucosa pink and moist. Throat: Oropharynx without redness, no tonsillar enlargement.

Neck: Neck supple without palpable masses or tenderness. Full range of motion, no lymphadenopathy.

Pulmonary: Clear and equal breath sounds bilaterally. No wheezes, rales, or rhonchi. Respiratory effort is regular and symmetrical.

Cardiovascular: Regular rate and rhythm, no murmurs, or gallops. Distal pulses are strong and equal bilaterally.

Breast: Inspection of the chest wall reveals a symmetrical contour. The patient has well-developed pectoral muscles bilaterally. There are no visible masses, nodules, or skin changes on the chest wall. There is no asymmetry or dimpling observed. Nipples are bilaterally symmetrical without any discharge, ulceration, or retraction.

GI: The abdomen is soft and nontender to palpation. There are no areas of rigidity or guarding. No rebound tenderness is seen during deep palpation. The patient does not grimace or show signs of discomfort during palpation. There is no evidence of organomegaly such as splenomegaly.

Male/female genital: Inspection of the male genitalia reveals no signs of swelling, redness, or lesions on the penis, scrotum, or perineal area. The penis is circumcised and without any abnormalities such as discharge or sores. The urethral meatus appears normal and without any discharge. The scrotum is symmetric and without swelling or masses.

GU: No urinary frequency, urgency, or dysuria were reported. No costovertebral angle tenderness was noted. no history of flank pain or any unusual sensations during urination.

Neuro: Cranial nerves 2–12 are intact. Muscle strength is symmetrical and appropriate in all extremities. The patient can perform a full range of active movements against resistance without weakness. There is no muscle atrophy or fasciculations noted No focal motor or sensory deficits observed. Deep tendon reflexes are symmetrical and brisk.

Musculoskeletal: The patient shows full and painless range of motion in all major joints, including the shoulders, elbows, and wrists. Active and passive movements are easily done without discomfort or limitation. Joints show no swelling, redness, or warmth. There is no visible or palpable muscle atrophy in any extremity.

Derm: Skin is clear with no lesions, rashes, or ecchymosis. No signs of excessive picking or scratching. No history of psoriasis reported.

Psychosocial: The patient maintains eye contact during the exam. His speech is clear and coherent, but he displays signs of anxiety, such as fidgeting and restlessness. No hallucinations, delusions, suicidal, or homicidal ideations were noted.

Misc. N/A

Mental Status Exam

Appearance: The patient appears alert and appropriately dressed. He displays mild restlessness and frequent fidgeting during the examination.

Behavior: The patient is cooperative and engages in conversation. He demonstrates signs of anxiety, such as tapping fingers and shifting in his seat.

Speech: The patient's speech is slightly rapid, with occasional interruptions. He is able to convey his thoughts and engage in coherent conversation.

Mood: The patient's mood appears anxious, as evidenced by his restlessness and signs of tension.

Affect: The patient's affect is somewhat constricted, showing limited emotional expressiveness.

Thought Content: Thought Content: The patient reports concerns about his anxiety symptoms and their impact on his daily life.

Thought Process: Thought process is coherent

Cognition/Intelligence: Alert and oriented to person, place, and time. He can perform basic calculations and answer questions accurately.

Clinical Insight: He is aware of the effect of his anxiety on his functioning and recognizes that seeking help is the right step

Clinical Judgment: The patient shows reasonable judgment and insight into his condition. He shows a willingness to engage in treatment.

Psychotherapy Note Based on the patient's symptoms, he is most likely suffering from generalized anxiety disorder. As such, the patient will most likely require both medication and psychotherapy. The most appropriate therapy for the patient would be cognitive-behavioral therapy, as it will help him understand and manage his thought patterns and identify triggers. He will also be able to gain coping strategies such as relaxation techniques to help him manage his symptoms during periods of extreme anxiety.

Therapeutic Technique Used: Cognitive-behavioral therapy

Session Focus and Theme: During the session, the main focus was to identify and address the patient's thought patterns, worries, and the effect they have on his daily functioning. This involved analyzing in detail his thought patterns and helping the patient understand that his worries were irrational. The therapist made use of the principles of Rational emotive behavior therapy.

Intervention Strategies Implemented: By using rational emotive behavior therapy strategies, the therapist helps the patient identify irrational beliefs and negative thought patterns that lead him to emotional or behavioral issues. The two techniques that the therapist used were humor and irony. The therapist first began by helping the patient identify his irrational beliefs, and then introduced humor and irony to help the patient understand the unrealistic nature of his beliefs.

Evidence of Patient Response: The patient was active throughout the session and showed a willingness to understand and apply the techniques given. “I am aware that most of the time my worries are irrational and even though it is difficult for me not to worry despite being aware of this, I am willing to learn and apply the strategies discussed so that I can effectively manage my symptoms."

Plan:

· Generalized anxiety disorder, 7- item; The result score of 15 showed positive symptoms for severe generalized anxiety disorder.

· A comprehensive metabolic panel was done to rule out any medical condition that might be causing symptoms such as electrolyte imbalances or kidney dysfunction.

Comprehensive Metabolic Panel

· Glucose: 80 mg/dL

· Blood Urea Nitrogen (BUN): 10 mg/dL

· Creatinine: 0.84 mg/dL

· Sodium: 140 mmol/L

· Potassium: 4.5 mmol/L

· Chloride: 100 mmol/L

· Carbon Dioxide (CO2): 23 mmol/L

· Calcium: 8.4 mg/dL

Differential Diagnoses

1. Panic Disorder: DSM-5 Code: 300.01, ICD-10 Code: F41.0

Panic disorder is an anxiety disorder in which a person experiences

recurring, unexpected panic attacks (Levey et al., 2020). These panic attacks cause a person to experience intense fear and physical symptoms such as a racing heart, fast breathing, and sweating. The GAD-7 screening tool helps rule out this condition.

2. Social Anxiety Disorder (Social Phobia): DSM-5 Code: 300.23, ICD-10 Code: F40.1

Social anxiety is a type of anxiety disorder that causes a person to experience intense and persistent fear of being watched and judged by others. People with this disorder tend to isolate themselves from others or social events (Kalin, 2020). Most of the patient's symptoms and the GAD-7 item rule out this condition.

Principal Diagnoses

1.Generalized Anxiety Disorder (GAD): DSM-5 Code: 300.02, ICD-10 Code: F41.1

Generalized anxiety disorder is an anxiety disorder whereby a person experiences extreme worries over various aspects of their lives (McDowell et al., 2019). A person with GAD may worry about their academics, finances, relationships, family, or health. Symptoms of GAD include restlessness, a sense of dread or fear, difficulty concentrating, and irritability. The patient's symptoms and GAD 7-item support this condition.

Plan:

Selective serotonin reuptake inhibitors (SSRIs) are identified as the best medications for in the treatment of generalized anxiety disorder (Carl et al., 2020). The patient was prescribed Lexapro 10 mg once a day taken orally. He was educated on the potential side effects of the medication to look out for such as nausea, drowsiness, and headaches. The cost of Lexapro is approximately $7.19 for 30, 10 mg tablet.

Diagnosis #1 Generalized anxiety disorder

Diagnostic Testing/Screening: Generalized anxiety disorder 7-item.

Pharmacological Treatment:

Name: Lexapro

Dosage: 10 mg

Route: taken orally

Frequency: once a day

Cost: The cost of Lexapro is approximately $7.19 for 30 10 mg tablet.

Non-Pharmacological Treatment: Cognitive -Behavioral-Therapy

Patient/Family Education:

1. Practice deep breathing exercises daily.

2. Maintain a consistent sleep schedule for better rest.

3. Limit caffeine intake to manage anxiety triggers.

4. Engage in regular physical activity to reduce tension.

5. Learn and use progressive muscle relaxation techniques.

6. Challenge negative thoughts with rational thinking.

Referrals: Psychotherapist

Follow-up: 2 weeks to assess treatment response.

Anticipatory Guidance:

1.Keep a journal to track anxious feelings and patterns.

2. Set small, achievable goals to build self-confidence.

3. Establish a daily routine to provide structure.

4. Prioritize healthy meals and avoid skipping them.

5. Engage in hobbies to distract from anxious thoughts.

6. Limit exposure to stressors, if possible.

Signature (with appropriate credentials): __________________________________________

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

References

Carl, E., Witcraft, S. M., Kauffman, B. Y., Gillespie, E. M., Becker, E. S., Cuijpers, P., ... & Powers, M. B. (2020). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials. Cognitive Behavior Therapy, 49(1), 1-21. https://doi.org/10.1080/16506073.2018.1560358

Kalin, N. H. (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365-367. https://doi.org/10.1176/appi.ajp.2020.20030305

Levey, D. F., Gelernter, J., Polimanti, R., Zhou, H., Cheng, Z., Aslan, M., ... & Stein, M. B. (2020). Reproducible genetic risk loci for anxiety: results from∼ 200,000 participants in the Million Veteran Program. American Journal of Psychiatry, 177(3), 223-232.https://doi.org/10.1176/appi.ajp.2019.19030256

McDowell, C. P., Dishman, R. K., Gordon, B. R., & Herring, M. P. (2019). Physical activity and anxiety: a systematic review and meta-analysis of prospective cohort studies. American Journal of Preventive Medicine, 57(4), 545-556.https://doi.org/10.1016/j.amepre.2019.05.012

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)__________P.S.____________________ Age _____18______

Date: ________08/20/2023________

RX _________Lexapro_____________________________

SIG: Lexapro 10 mg taken orally once a day. The cost of Lexapro is approximately $7.19 for 30 10 mg tablet.

Dispense: _______30 tablets____ Refill: ________0_________

No Substitution

Signature: ____________________________________________________________