Patient Intake and History
The patient is a 26-year-old college graduate who is currently euthymic but who has a history of major depressive episodes
He has experienced major depressive episodes, mostly untreated, of varying lengths and severities since he was a teenager
His symptoms have included insomnia, despondent thoughts, depressed mood, low interest in activities, poor energy, and impaired cognition
He says his self-esteem drops and he feels rejection-sensitive and guilt-ridden for no apparent reason
He has never had suicidal thoughts
Some of the depressive episodes have been incapacitating and have interfered with school and work
He appears to have good inter-episode recovery and is able to return to class and work
The patient also has symptoms of social anxiety
He is often nervous around new people and acquaintances
He experiences anticipatory anxiety and will avoid certain social events
These symptoms are present regardless of his affective state
He has asked for a consultation because he has legal issues regarding drinking and driving that he thinks were likely fueled by his psychiatric symptoms
At the time of the infraction (several months ago, just before graduating college), he had been started on a selective serotonin reuptake inhibitor (SSRI) for the depression and SAD symptoms
Within days of starting he experienced elevated mood in a sustained fashion over several days
He lost all anxiety, fear, and avoidance
He was unusually talkative; had racing thoughts; was distractible, hyperactive, and impulsive; and had decreased need for sleep
He exhibited grandiosity, in which he felt invincible and that the law did not apply to him; this led him to purposefully antagonize a man in a bar, drive while drinking, and challenge authority when police were called
The mood elevation is complicated by the fact that the patient admits to heavy alcohol use on weekends throughout college
The mood elevation abated with cessation of the SSRI treatment
He has now completed college; he has few friends in the immediate area but his family is very supportive
He wants to be a news reporter and is planning on applying to graduate school
The patient has no family history of bipolar disorder; his mother has generalized anxiety disorder (GAD)
He is not currently taking any medications
Vitals:
Please use the case study template to complete the case and answer the questions listed below:
Requirements: Need to answer all questions
670 Case Study Psychiatric SOAP Note Template with Rx
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.
| Criteria | Clinical Notes |
| Subjective | |
| 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. | |
| Objective | |
| 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. | |
| Assessment | |
| 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. | |
| Plan |
|
| 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 plan should relate directly to your Assessment. |
PRESCRIPTION (for student use-Not VALID)
Herzing Medical Clinic
15 Medical Clinic Circle
Destination, SS, 00123
Phone: 123 456 7890
Fax: 123 456 7890
PMHNP Student Jane Herzing, APRN
License # SS 17245A
NPI # 1234567899
PATIENT DETAILS: DATE:
NAME
………………Patient Doe……………………………………………………………..…..
DOB …….………………………………………………………..
ADDRESS
……………3515 Admiral Way……………………………………………………………
…………….Destination, SS 00123……………………………………………………..
_______________
Prescriber’s signature
Copy any Case study questions from the instructions and answer here.
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