The patient, a 65-year-old female comes to the clinic with complaints of persistent feelings of sadness that began approximately 5 months ago. The patient admitted that w

Psychiatric SOAP Note Template

Encounter date: _______01/07/2023_________________

Patient Initials: ___R.S.___ Gender: M/F/Transgender __Female__ Age:  _65____ Race: _Caucasian____ Ethnicity __White__

Reason for Seeking Health Care: “I do not know what to do about these feelings of extreme sadness all the time. I have lost interest in anything and have not found any pleasure in life ever since my husband died 5 months ago.

HPI: The patient, a 65-year-old female comes to the clinic with complaints of persistent feelings of sadness that began approximately 5 months ago. The patient admitted that when the symptoms first began five months ago they were mild and she attributed them to the loss of her husband.  The patient admitted that the symptoms have since progressed impacting her daily functioning. The patient admitted that she has lost interest in any activities she once thought enjoyable and struggles to find the right motivation to do anything. She admitted that she has also been experiencing difficulty in falling or staying asleep and is often fatigued during the day as a result. The patient admitted that she feels like a burden to her adult children and has been having constant thoughts of suicide. The patient admitted that her feelings of sadness often increase when she comes into contact with her husband’s things. She admitted that talking to her eldest daughter often provides temporary relief. The patient admitted to losing a couple of pounds over the 5 months due to a significant loss of appetite. The patient admitted that she rates her symptoms on a severity level of 8 over 10 as these symptoms have greatly impacted her daily functioning. The patient admitted to taking 50 mg of losartan taken orally once a day in the morning for hypertension. The patient denied fever, chills, or night sweats.

SI/HI: The patient denied a history of suicidal attempts or history.

Sleep:  The patient admitted that she has been having difficulty falling or staying asleep for the last 5 months

Appetite: The patient admitted to losing several pounds due to a decreased appetite.

Allergies(Drug/Food/Latex/Environmental/Herbal): _________The patient denied being allergic to any drug, food, latex, environment, or herbal__________________________

Current perception of Health:         Excellent     Good    Fair Poor

Psychiatric History:

Inpatient hospitalizations:

Date

Hospital

Diagnoses

Length of Stay

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: The patient denied a history of suicidal attempts or engaging in self-harming behaviors. She admitted to experiencing constant thoughts of suicide for the last two months.

Past Medical History

● Major/Chronic Illnesses: The patient admitted to a diagnosis of hypertension, which she was diagnosed with at the age of 30. She admitted that the disease is currently active.

● Trauma/Injury: She denied any recent trauma or injury but admitted to occasional falls in the past that resulted in minor injuries.

● Hospitalizations: She admitted to being hospitalized due to the cesarean section deliveries of her last two children in 1986 and 1989.

Past Surgical History: The patient was admitted to cesarean section delivery, which necessitated surgical incisions to be made on her abdomen and uterus.

Current psychotropic medications:

_________________None________________________                 ________________________________

_________________________________________              ________________________________

_________________________________________              ________________________________

Current prescription medications:

50 mg of losartan is taken orally once a day in the morning for hypertension. ______________________________                        ________________________________

_________________________________________              ________________________________

_________________________________________              ________________________________

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 mother died at the age of 70 and had a history of bipolar disorder and major depressive disorder, which she managed with medication and psychotherapy over the years.

● The patient’s father died in a car accident when he was 78 years old. He had a history of alcohol use disorder, and which he poorly managed. He occasionally attended psychotherapy.

● The patient’s elder brother is currently alive and is 67 years old. He has a history of generalized anxiety disorder, which he has manages with medication and occasional psychotherapy over the years.

●      The patient’s second-born son is currently 40 years old and was diagnosed with high-functioning autism spectrum disorder when he was 4 years old.

Social History

Lives: Single-family House/Condo/ with stairs: _______lives in a 3 bedroom family house ____ Marital Status:___Widow____

Education: ______ Bachelors degree in culinary arts. _______

Employment Status: __Self-employed____ Current/Previous occupation type: _________Chef________

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 admitted to having four children who live separately in different states. She admitted to currently living alone since her husband died five months ago. She admitted to having three pet dogs that act as companions to her.

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient admitted she was born in Miami, Florida, and is the last of three siblings. She admitted to having a happy childhood, even though they were not well off financially. She admitted to living in a 3-bedroom family house with three pet dogs. She admitted that she used to enjoy playing tennis with friends but has not played in 5 months due to a lack of interest and motivation. She denied a history of abuse, violence, or being involved in any criminal activities. She admitted that she used to have a lot of friends, but she has been isolating herself due to a strong desire to be alone. She admitted to being married for 40 years.

Health Maintenance

Screening Tests:

The patient received a mammogram on June 15, 2015, and the results were negative for any micro-calcifications.

The patient received a pap smear on June 15, 2015 and the results were negative for any cellular changes/

The patient received a colonoscopy on June 15, 2015, and the results were negative for any polyps or abnormal growth.

The patient received a Dual-Energy X-ray Absorptiometry scan on June 15, 2015, and the T-score results of -1.0 at the hip and spine indicated a normal range.

Exposures: No exposure to any harmful substances

Immunization HX:

The patient is up to date with all her immunizations, including the flu vaccine, which she received on August 15, 2022.

Review of Systems:

General: The patient admitted to consistent feelings of sadness, a lack of interest in things once enjoyed, such as tennis, a lack of motivation, a decreased appetite, and difficulty falling or staying asleep.

HEENT: She admitted to having occasional tension headaches but denied any scalp tenderness or lesions. She admitted to having clear vision and no negative reaction to light. She denied having any hearing difficulties or noticing any abnormalities in her ears. She denied nasal congestion, bleeding, or deviations. She denied any more odor, sores, bleeding gums, missing teeth, broken teeth, or difficulty swallowing.

Neck: She admitted to normal neck positioning with a full range of motion. She denied any masses, patches, or lesions on her neck.

Lungs: She admitted to a regular breathing rate at rest and denies any shortness of breath or abnormal chest expansion and contraction.

Cardiovascular: She denied irregular heart rate and rhythm, denied any palpitations or chest pain.

Breast: She denied noticing any breast lumps, pain, or tenderness. She admitted to having regular mammograms and performing monthly self-examinations.

GI: She has admitted to having regular bowel movements without any diarrhea, constipation, abdominal pain, bloody stools, or vomiting.

Female genital: She denies any abnormal bleeding, discharge, sores, or masses in the genital area.

GU: She admitted to a typical urinary frequency without any pain, changes in urine color, blood in urine, or odor. She denies any difficulties with urination or urinary incontinence.

Neuro: She admitted to having issues concentrating but denied any neurological deficits or memory problems.

Musculoskeletal: She denied noticing any joint swelling, redness, tenderness, or stiffness. She denies any weakness or fatigue.

Activity & Exercise: She admitted that she used to have regular walks with her husband every evening but has not taken any walks since her husband passed away.

Psychosocial: She admits to feeling extreme sadness and having a loss of interest in activities such as tennis. She admitted to constant suicidal thoughts but denied any homicidal thoughts.

Derma: She admitted to having healthy skin without any rashes, itching, acne, swelling, or redness.

Nutrition: She admitted that she used to maintain a balanced diet with regular meals but has had a significant loss of appetite, which has resulted in significant weight loss.

Sleep/Rest: She admitted to having difficulty falling or staying asleep, which often leaves her tired during the day.

LMP: She admits that her last menstruation was 20 years ago. She admitted that she used to have regular periods that occurred every 28 days. She admitted that the menstrual flow was often accompanied by menstrual cramps.

STI Hx: She denies any history of sexually transmitted infections or symptoms such as painful urination, abnormal discharge, odors, or bleeding.

Physical Exam

BP____123/61____TPR___96.5__ HR: 73_____ RR: _19___Ht. __5’3___ Wt. _53_____ BMI (percentile) __20.7 kg/m2 (Normal range).

General: The patient appears generally fatigued and has a noticeable weight loss. She appeared withdrawn and consistently sad. She was wearing a wrinkled black dress and appeared disheveled.

HEENT: The patient has a normal-sized head with no signs of injury, tenderness, or trauma. She complains of occasional blurry vision and increased sensitivity to light. She has no hearing difficulties, and her ears show no discharge or bleeding. Her gums appear pale, and she has a dry mouth and tongue with no ulcers.

Neck: She has a slightly forward head posture with a limited range of motion. There are no masses, tenderness, or palpable lymph nodes in her neck.

Pulmonary: Clear to auscultation bilaterally. No wheezes, crackles, or decreased breath sounds. There were no signs of respiratory distress.

Cardiovascular: She has a regular heart rate, but it is slightly elevated. There are no signs of edema in the extremities, cyanosis, clubbing of the nails, or any abnormalities in the peripheral pulses.

Breast: breasts are symmetrical, and the breast skin is free of redness, dimpling, or changes in texture.

GI: Soft and non-tender. Bowel sounds are present in all quadrants. No palpable masses or organomegaly. No abdominal tenderness or guarding.

Male/female genital: No visible abnormalities, lesions, or discoloration. There are no signs of swelling or inflammation. Pubic hair is sparse and gray in appearance, consistent with age.

GU: healthy appearance of urine with no odors, no change in color of urine, blood, or sediments in urine. No reports of abnormal urinary frequency, urgency, or incontinence.

Neuro: Alert and oriented to person, place, and time. Unimpaired cranial nerves, sensation, and motor strength. Normal coordination and gait. No tremors or involuntary movements.

Musculoskeletal: Typical muscle tone and bulk. Full range of motion in all extremities. No joint deformities, swelling, or tenderness.

Derm: Dry skin with mild scaling on extremities. No rashes, lesions, or significant discoloration.

Psychosocial: The patient is alert and oriented to place, time, and person. Appears sad, and insight and judgment are impaired. There is a lack of motivation for self-care and social activities.

Misc. No additional information was collected.

Mental Status Exam

Appearance: The patient appears sad, her appearance is disheveled, indicating a lack of self-care. Her posture is slumped, and she has trouble making eye contact.

Behavior:  Psychomotor agitation is observed; she is constantly fidgeting with her hands.

Speech: The patient’s speech is slow and low in volume. Before she speaks, she pauses and is hesitant to respond.

Mood: The patient’s mood is consistently depressed throughout the examination. She admits to having feelings of sadness and hopelessness and feeling like a burden to others.

Affect: The patient exhibits a restricted and constricted affect. There are very few facial expressions.

Thought Content: The patient is self-critical and displays pessimistic thoughts.  No delusions or hallucinations were noted.

Cognition/Intelligence: The patient demonstrates intact cognitive abilities during the examination.

Clinical Insight: The patient has some insight into her depression, admitting that she is experiencing symptoms of depression and that she needs help even though she is not sure if treatment will work.

Clinical Judgment: The patient’s judgment appears moderately impaired as she displays difficulty in problem-solving and making decisions.

 

Plan:

Differential Diagnoses

1. Major Depressive Disorder DSM-5 296.20(F32)

2. Bipolar II Disorder DSM-5 296.89 (F31.81)

Bipolar II disorder is characterized by high episodes of euphoria and low episodes of

depression, and are known together as hypomania (Rhee et al., 2020). The main difference bipolar and major depressive disorder is that depression is unipolar, meaning that there are no mania episodes but bipolar disorder includes symptoms of mania

Principal Diagnoses

1. Major Depressive Disorder DSM-5 296.20 (F32)

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest (Dwyer et al., 2020). Major depressive disorder typically affects how a person feels, thinks, and behaves. Depression can lead to a variety of emotional and physical problems, as a person may have trouble doing normal day-to-day activities and sometimes feel as if life is worthless.

Plan

Selective serotonin reuptake inhibitors are considered the first line of treatment for major depressive disorder due to their safety and minimal side effects (Widge et al., 2019). The patient has therefore been prescribed Fluoxetine 10 mg as an initial dosage to minimize potential side effects at the beginning of treatment. The patient was instructed to take fluoxetine 10 mg orally once a day. The cost for a fluoxetine oral capsule of 40 mg is around $13 for a supply of 30 capsules. The patient was recommended cognitive behavioral therapy as a form of psychotherapy because it will help her identify and alter negative thought patterns.

Diagnosis #1 Major Depressive Disorder

Diagnostic Testing/Screening: PHQ-9

Pharmacological Treatment:

Name: Fluoxetine

Dosage:10 mg

Route: Mouth

Frequency: once a day

Cost: The cost for a fluoxetine oral capsule of 40 mg is around $13 for a supply of 30 capsules.

Non-Pharmacological Treatment: Cognitive behavioral therapy

Education:

1. Take fluoxetine as prescribed.

2. Take the medication at the same time each day.

3. Do not skip doses.

4. Report any side effects immediately.

5. Avoid abrupt discontinuation without consulting the mental health provider

6. Attend scheduled follow-up appointments

Referrals: psychotherapy

Follow-up: 2 weeks to assess symptoms/

Anticipatory Guidance:

1. Keep track of your mood changes.

2. Avoid alcohol while taking fluoxetine.

3. Be patient; it may take several weeks to notice improvement.

4. Follow a regular sleep schedule.

5. Engage in regular physical activity.

6. Seek support from friends and family.

Signature (with appropriate credentials): __________________________________________

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

References

Dwyer, J. B., Aftab, A., Radhakrishnan, R., Widge, A., Rodriguez, C. I., Carpenter, L. L., … & APA council of the research task force on novel biomarkers and treatments. (2020). Hormonal treatments for major depressive disorder: State of the art. American Journal of Psychiatry, 177(8), 686-705.https://doi.org/10.1176/appi.ajp.2020.19080848

Rhee, T. G., Olfson, M., Nierenberg, A. A., & Wilkinson, S. T. (2020). 20-year trends in the pharmacologic treatment of bipolar disorder by psychiatrists in outpatient care settings. American Journal of Psychiatry, 177(8), 706-715. https://doi.org/10.1176/appi.ajp.2020.19091000

Widge, A. S., Bilge, M. T., Montana, R., Chang, W., Rodriguez, C. I., Deckersbach, T., … & Nemeroff, C. B. (2019). Electroencephalographic biomarkers for treatment response prediction in major depressive illness: A meta-analysis. American Journal of Psychiatry, 176(1), 44-56. https://doi.org/10.1176/appi.ajp.2018.17121358

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

Patient Name: (Initials)___________R.S.___________________        Age ______65_____

Date: _______01/07/2023________

RX _______Fluoxetine_______________________________

SIG: 10 mg of fluoxetine taken once a day by mouth. The cost for a fluoxetine oral capsule of 40 mg is around $13 for a supply of 30 capsules.

Dispense:  __30 capsules_________ Refill: ________0_________

 

No Substitution

Signature:____________________________________________________________