P. D is a 54 -year- male with current diagnoses of bipolar and related disorder due to another medical condition, with manic- or hypomanic-like episodes, who was seen today at the clinic for psychiatric evaluation and medication management. As per report from pt stating, ‘ I have feelings of depression, always anxious, dealing with anger issues, stress, and health problems.”
He reported difficulty with managing stress and anxiety and difficulty with trusting people around him. He is alert and oriented x3 to person, place and time. He denied having suicidal and homicidal ideation. Pt denied having any hallucinations. He has normal speech and was cooperative. He denied using assistive device during ambulation. He stated that his Mood was anxious stating “I have lot going especially Healthwise.” His affect is full. His thought process was appropriate, or goal directed. His memory remains intact. His insight and judgment to his mental illness remain fair. He endorsed having history of substance abuse stating, “I drink alcohol – beer, and smoke PCP.” He stated that he started drinking alcohol when he was young, while PCP was when he was 32 years old. Pt denied having family history of substance abuse. He endorsed allergic reaction to med – stating “Lisinopril, Tylenol causing throat and tongue swollen and Alive causing hives.” He denied having family history of mental illness. Pt denied having family history of mental illness. He stated that he has associate degree. He stated that he is living in a Transition facility (hotel) and the living condition is good at this time. He endorsed having been incarcerated for long time ago for domestic violence and denied having any pending court case at this time.
Pt was placed on the following medication: Seroquel 200 mg 1 tablet at bedtime po x30 days Pt was educated on the benefits and risk of medications, probable side effects and interaction to report, or call 911 for ER, alternative treatment and was encouraged to take medication as prescribed.
Instructions from the Instructor:
In the Subjective section, provide:
Chief complaint- this is the reason why the patient is at the clinic/hospital for THIS visit. “I was started on Sertraline 4 months ago, but I don’t feel any changes with my depression.”
History of present illness (HPI) – Characteristics of the symptoms or complaint; Course or how long symptoms have been present; Any triggers, precursors, or aggravators; any other symptoms noted (anxiety, lack of motivation, decreased energy/fatigue); Any treatments or alleviating factors noted; Client’s thoughts or any additional pertinent information that supports this visit. (Please only list the information that is relevant to the presenting problem. Any other crucial past psych history info can go below).
Past psychiatric history – including inpatient and outpatient psychiatric treatment and medications with the reason for discontinuation. Any past suicide attempts.
Medication trials and current medications – include psychotropic meds.
Past medical history – includes prior surgeries, illness, and injuries. You can list any current non-psychotropic meds here.
Family history- medical and psychiatric, including past completed suicides.
Social history – born or raised, occupation or schooling/grade, marital status/children, nicotine/caffeine/alcohol or drug use, legal issues (incarcerated), physical activity, religion, and any trauma (physical, emotional, or sexual)
Pertinent substance use, family psychiatric/substance use, social, and medical history – nicotine/caffeine/alcohol or drug use, legal issues (incarcerated), physical activity, religion, and any trauma (physical, emotional, or sexual)
ROS (Review of Systems) Please only document the information asked about/completed. Remember, this is psychiatry, and generally we don’t auscultate breath sounds, etc, in visits.
Reproductive (including last menstrual period or pregnancy)
In the Objective section, provide:
Mental Status Exam/Observation (Please use a list format and avoid long paragraphs) MSE are usually concise and direct.
Assess Suicidal Ideations, Homicidal Ideations, and Psychotic Symptoms
Orientation – person, place, time, situation
Thought Process – logical, linear, goal-directed, tangential, circumstantial, loose)
Thought content/perceptions – hallucinations, ideas of reference, paranoia, delusions, obsessions/compulsions)
Memory – include immediate, recent, and remote
Diagnostic results, including any labs (Chemistries, CBC, Thyroid studies, etc.) imaging, or other assessments needed to develop the differential diagnoses (including screening instruments – PHQ, PCL, Beck, etc.). Screening tools are a great process for measured base care (how well is the patient progressing with the current treatment plan)
******** Remember labs are important. If you did not order labs, you can discuss which labs you would like to order or which labs are important to review. ******************
In the Assessment section, provide:
Diagnosis/Diagnoses – include all mental health diagnoses and the ICD-10 codes for each. Be Specific with diagnosis. Example: Major depressive disorder, recurrent, moderate F33.1; General anxiety disorder F41.1
At least three differentials with supporting evidence. List them from top priority to least priority. The differential diagnoses can be found in your DSM-V book, located in each section for the diagnosis.
You are required to include at least three evidence-based, peer-reviewed journal articles or evidence-based guidelines which relate to this case to support your diagnostics and differential diagnoses and treatment plan. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. (Ensure that this is concise. You can accomplish this with no more than 1-2 paragraphs for this section.)
Also be sure to state why you are ruling out the diagnosis
Example of how to make this section concise:
Diagnosis: Major Depressive Disorder, Recurrent, Mild F33.0 is the primary diagnosis because the patient displays symptoms of sadness, difficulty with cleaning, poor appetite, and poor sleep, aligning with the DSM criteria for MDD mild recurrent. According to Blank et al. (2021), people with MDD recurrent mild may experience these symptoms for several months without seeking help due to the minimization of symptoms. Bipolar 1 (F31.1) and Bipolar 2 (F31.81) were differential diagnoses considered. They were ruled out because although the patient reported irritability and sleep disturbance, they have never experienced hypomania or mania. According to Blank et al. (2020), to meet the criteria for Bipolar 1 (F31.1) , you must have experienced at least one manic episode that consisted of ……. Additionally Blank et al. (2023) note that hypomania is required to diagnose Bipolar 2 (F31.81) and can be distinguished from MDD by closely differentiating hypomania from irritability occurring in unipolar depression.
***** Be sure to connect this diagnosis with the patient symptoms and explain which symptoms the patient had to solidify the diagnosis********
(Ensure that this is concise. You can accomplish this with no more than 1-2 paragraphs for this section.)
(Please be sure to document this information in list format like below, avoid paragraphs as this distracts from clarity.)
Be sure to include a brief rationale for your treatment plan. EX: Zoloft was chosen because it is FDA approved to treat depression in children and adults.
The plan should also include the information below:
All medications ordered, including dose, route, time, number of tabs/caps dispensed, and number of refills.
All non-pharmacological treatment, including psychotherapy (individual, family, group), medical evaluations, and special programs – recovery/addiction.
Referrals/Consults – community, medical.
Collaboration with the multidisciplinary team.
Specific labs and diagnostic tests ordered/pending.
Follow-up plan with timeline – Return to clinic in 2 months on October 9, 2022, @ 10 am
Patient teaching – includes diagnosis, medication, treatment, emergency procedures, suicide hotlines, etc.
Reflect: (Please no more than two paragraphs)
Discuss what you learned and what you might do differently. Also, Include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
You are required to include at least three evidence-based, peer-reviewed journal articles or evidence-based guidelines which relate to this case to support your diagnostics and differential diagnoses as well as the treatment plan.
Be sure to use the correct APA 7th edition formatting.
Do NOT submit actual journal articles with your SOAP note.
You only must submit a reference page with your SOAP note. Please limit citations to your reflections and to support any diagnostic reasoning for why you selected a diagnosis.