psych eval 3

SOAP NOTES- PICK ONE

60-Minute Initial Psychiatric Evaluation – PTSD, Anxiety, and Smoking

Demographics: JR is a 58-year-old male, divorced, retired military veteran, living alone.

Visit Type: 60-minute initial psychiatric evaluation via telemedicine.

Chief Complaint: "I still have nightmares about my military experience, and smoking helps calm my nerves."

Psychiatric Diagnoses:

· PTSD (F43.10)

· Generalized anxiety disorder (F41.1)

· Nicotine dependence, cigarettes (F17.210)

Medical Comorbidities: Hypertension, hyperlipidemia, and chronic back pain.

Current Medications: Lisinopril 10 mg daily, atorvastatin 20 mg nightly.

Psychiatric History: Combat-related trauma with nightmares, flashbacks, and hypervigilance. Previously attended VA counseling. No psychiatric hospitalizations or suicide attempts.

Substance Use: Smokes 1 pack daily for 35 years (35 pack-years). Occasional alcohol use; denies illicit drugs.

Social Problems: Social isolation, relationship difficulties, and chronic pain.

Procedures: Psychiatric evaluation, MSE, PTSD and anxiety screening, tobacco assessment, and suicide risk assessment.

Clinical Note: Reports persistent nightmares, flashbacks, hypervigilance, anxiety, and insomnia related to military trauma. Smokes daily to manage stress. Denies SI/HI, mania, or psychosis.

S (Subjective): Nightmares 3–4 times weekly, excessive worry, and poor sleep averaging 4–5 hours nightly. Motivated to quit smoking.

O (Objective): Alert, oriented ×4, cooperative. Anxious mood, constricted affect, logical thoughts, fair insight and judgment.

A (Assessment): PTSD with persistent trauma symptoms, comorbid GAD, and nicotine dependence. No acute safety concerns.

P (Plan): Start sertraline 25 mg daily for 7 days, then 50 mg daily if tolerated. Initiate nicotine patch 21 mg daily. Recommend trauma-focused CBT and smoking cessation counseling. Monitor symptoms and medication response. Follow up in 2 weeks.

New Medications:

· Sertraline 25 mg → 50 mg daily.

· Nicotine patch 21 mg daily.

Activity Time: 60 minutes

Complexity: Moderate

CPT: 90792

ICD-10-CM: F43.10, F41.1, F17.210

60-Minute Initial Psychiatric Evaluation – Depression and Anxiety

Demographics: SB is a 31-year-old female, single, employed full-time as a registered nurse, living alone.

Visit Type: 60-minute initial psychiatric evaluation via secure telemedicine.

Reason for Visit: Initial evaluation of worsening depression and anxiety.

Chief Complaint: "I've been feeling overwhelmed, anxious, and depressed for months."

Psychiatric Diagnoses:

· Major depressive disorder, recurrent, moderate (F33.1)

· Generalized anxiety disorder (F41.1)

Medical Comorbidities: Asthma and GERD.

Current Medications:

· Albuterol inhaler PRN

· Omeprazole 20 mg PO daily

Psychiatric History: Two previous depressive episodes. No psychiatric hospitalizations or suicide attempts. Previously attended counseling. No prior psychiatric medications.

Family Psychiatric History: Mother with depression.

Social Problems: Occupational stress, financial difficulties, and limited social support.

Procedures: Comprehensive psychiatric evaluation, MSE, PHQ-9, GAD-7, medication reconciliation, and suicide risk assessment.

Clinical Note: Patient reports three months of worsening depressed mood, anhedonia, fatigue, excessive worry, and difficulty concentrating. Anxiety symptoms have been present for over one year. Denies substance misuse, mania, psychosis, SI, or HI.

S (Subjective): Reports persistent sadness, excessive worrying, irritability, and poor motivation. Sleeps 5–6 hours nightly. Appetite decreased.

O (Objective): Alert, oriented ×4, cooperative. Mood depressed and anxious, affect constricted. Speech normal, thought process logical, insight and judgment intact. PHQ-9: 17; GAD-7: 15.

A (Assessment): Recurrent MDD, moderate, and GAD with significant occupational and social impairment. No acute safety concerns identified.

P (Plan): Start sertraline 25 mg PO daily for one week, then increase to 50 mg daily if tolerated. Recommend CBT and behavioral activation. Discuss medication risks, benefits, side effects, and delayed therapeutic response. Review safety plan and crisis resources. Follow up in 2–4 weeks.

Medication Change: Initiate sertraline 25 mg daily × 7 days, then 50 mg daily as tolerated.

Activity Time: 60 minutes

Complexity: Moderate

CPT: 90792 – Psychiatric diagnostic evaluation with medical services.

ICD-10-CM: F33.1, F41.1

45-Minute Psychiatric Follow-Up – OCD and Anxiety

Demographics: AC is a 35-year-old female, married, employed full-time as an accountant, living with her husband and two children.

Visit Type: 45-minute psychiatric follow-up via secure telemedicine.

Reason for Visit: Worsening obsessive thoughts and anxiety.

Chief Complaint: "I keep checking things repeatedly, and it's affecting my daily life."

Psychiatric Diagnoses:

· Obsessive-compulsive disorder (F42.2)

· Generalized anxiety disorder (F41.1)

Medical Comorbidities: Hypothyroidism and seasonal allergies.

Current Medications:

· Fluoxetine 40 mg PO daily

· Levothyroxine 75 mcg PO daily

· Cetirizine 10 mg PO daily PRN

Social Problems: Occupational stress, parenting responsibilities, and marital tension.

Procedures: Psychiatric assessment, MSE, medication reconciliation, Y-BOCS screening, and suicide risk assessment.

Clinical Note: Patient reports persistent intrusive thoughts and repetitive checking behaviors despite eight weeks of fluoxetine 40 mg daily. Compulsions interfere with work and family activities. Reports medication adherence without significant side effects. Denies SI/HI, mania, or psychosis.

S (Subjective): Reports excessive worry, intrusive thoughts, and checking doors and appliances repeatedly. Sleeps 6 hours nightly. Appetite stable.

O (Objective): Alert, oriented ×4, cooperative. Mood anxious, affect congruent. Speech normal, thought process logical, insight and judgment intact.

A (Assessment): OCD inadequately controlled on current treatment. GAD remains symptomatic. No acute safety concerns.

P (Plan): Increase fluoxetine to 60 mg daily after reviewing tolerability and bipolar history. Recommend CBT with exposure and response prevention (ERP). Monitor anxiety, compulsions, adverse effects, and suicidality. Follow up in 4 weeks.

Medication Change: Fluoxetine 40 mg → 60 mg PO daily.

Activity Time: 45 minutes

Complexity: Moderate

CPT: 99215 if supported by 45 minutes of qualifying clinician time; otherwise select the level supported by MDM.

ICD-10-CM: F42.2, F41.1

45-Minute Psychiatric Follow-Up – PTSD and Panic Disorder

Demographics: NR is a 46-year-old female, divorced, employed full-time as a medical receptionist, living with her daughter.

Visit Type: 45-minute psychiatric follow-up via secure audio/video telemedicine.

Reason for Visit: Medication management and evaluation of PTSD and panic symptoms.

Chief Complaint: "My panic attacks have improved, but I'm still having nightmares and trouble sleeping."

Psychiatric Diagnoses:

· Posttraumatic stress disorder (F43.10)

· Panic disorder (F41.0)

Medical Comorbidities: Hypertension and GERD.

Current Medications:

· Venlafaxine XR 75 mg PO daily

· Prazosin 1 mg PO nightly

· Amlodipine 5 mg PO daily

· Omeprazole 20 mg PO daily

Social Problems: History of domestic violence, occupational stress, and limited social support.

Procedures: Psychiatric assessment, MSE, medication reconciliation, PTSD screening, panic symptom evaluation, and suicide risk assessment.

Clinical Note: Patient reports fewer panic attacks and improved daytime anxiety. Continues to experience trauma-related nightmares three nights weekly, hypervigilance, and interrupted sleep. Adherent to medications without significant adverse effects. Denies SI/HI, mania, or psychosis.

S (Subjective): Reports improved anxiety but persistent nightmares and sleep disturbances. Sleeps approximately 5–6 hours nightly. Appetite stable.

O (Objective): Alert, oriented ×4, cooperative. Mood mildly anxious, affect congruent. Speech normal, thought process logical, insight and judgment intact.

A (Assessment): PTSD partially controlled with persistent nightmares. Panic disorder improving. No acute psychiatric safety concerns.

P (Plan): Continue venlafaxine XR 75 mg daily. Increase prazosin to 2 mg nightly if blood pressure and orthostatic assessment permit. Continue trauma-focused CBT and sleep hygiene. Monitor nightmares, dizziness, blood pressure, and medication response. Follow up in 4 weeks.

Medication Change: Prazosin 1 mg → 2 mg PO nightly, contingent on blood pressure and tolerability.

Activity Time: 45 minutes

Complexity: Moderate

CPT: 99215 if supported by 45 minutes of qualifying clinician time; otherwise select the level supported by MDM.

ICD-10-CM: F43.10, F41.0