Description
-Chief Complaint: “i feel bad”
History of Present Illness:
Patient is a 59 year old male with PPHx of alcohol use disorder, MDD, and PMHx of DVTs, PE, and BPH who was admitted to for medical stabilization of acute cholecystitis. psych consulted for mgt of depression and AUD.
Patient seen today seen at bedside, meds, labs and chart reviewed. Upon evaluation today, pt states mood is “not good” and reporting stomach pain, nausea, anxiety, HA; Denies hx of DTs or SZ in the past, but c/o moderate etoh withdrawals. states after HRC detox in 10/2023, pt was in rehab for 90 days and did well; was sober. he went to a sober home after but didnt like the rules so he left after a week. he relapsed immediately. has been street homeless and subsequently developed feelings of hopelessness and worthlessness. He has poor social support – all his family members are deceased except for 1 son, though they are estranged. He is not on psychotropic medication. states he did not follow up with outpt tx and psychotropic rx. states when he was taking his rx he did well. He interested in restarting psychotropic medications for mood. per chart review was last on fluoxetine 10mg He denies any sxs of psychosis, mania, adamantly denies any active suicidal thoughts nor death wishes, intent or plan. He is agreeable to go to Rehab program.
Outpatient: nonadherent
Compliance: intermittent
Hospitalizations: multiple for alcohol detox/withdrawal, most recent HRC 03/2022
State Hospitalizations: denies
Suicide Hx: denies
SUBSTANCE USE HISTORY
Etoh: endorses daily use of 1L vodka daily
Drugs: denied
Detox: multiple times
Rehab: endorses, previously at Camillus House
Smoking Status
Current everyday tobacco user
PAST MEDICAL HISTORY
see chart
FAMILY HISTORY
Medical: Father: Cancer of colon; Hypertension
Psychiatric disorders: denied
Alcohol/Substance use disorder: denied
Suicide or suicide attempts: denied
PSYCHOSOCIAL HISTORY:
Born in Puerto Rico
family members deceased
divorced, 1 son
Legal: Denied
Employment: Unemployed, receives disability checks
Living situation: Homeless
-Hx of trauma: No
Patient appearance: appears stated age, fairly groomed, good hygiene
Behavior: calm, appropriate
Attitude: cooperative
Eye contact: fair
Motor function: no psychomotor agitation + tremors or retardation
Orientation: person, place, time, situation
Speech: normal rate/tone/volume
Mood: “better”
Affect: mood congruent, euthymic
Thought Process: organized
Thought Content:
Delusions: None
Perceptual disturbances: None
Insight: fair
Judgment: fair
Attention: attentive
Concentration: intact
Diagnoses
Thrombocytopenia, unspecified (D69.6)
Alcoholic cirrhosis of liver without ascites (K70.30)
Abnormal levels of other serum enzymes (R74.8)
Alcohol dependence, uncomplicated (F10.20)
Epigastric pain (R10.13)
End of Diagnoses List
Psychiatric Consult Recommendations:
Patient is a 59 year old male with PPHx of alcohol use disorder, MDD, and PMHx of DVTs, PE, and BPH who was admitted to for medical stabilization of acute cholecystitis. psych consulted for mgt of depression and AUD. now facing uncomplicated withdrawal and mild depressive symptoms. Not a danger to self or others. In need of detox and treatment for alcohol use disorder as below.
Medication recommendations:
-Continue Ativan taper, until discontinue.
-Continue rally pack, with MTV, folic acid 1mg and thiamine 100mg qd
-restart Fluoxetine 10mg qd
-can consider restarting naltrexone 50mg po daily for alcohol use disorder – provide Rx at discharge. Pt has not used opioids during the last week.
Labs/Imaging recommendations:
As per primary team
Monitor LFTs .
Safety
-At risk of harm to self or others: No
-Needs 1:1 sitter: No
-Requires video monitoring: No
-Baker Act status: Lift
-Marchman act status: No – pt requesting voluntary treatments
Precautions:
-Fall risk: Yes
-Seizure: Yes during withdrawal
-Elopement: No
-Suicide: No
-Substance use withdrawal: Yes monitor CIWA
Other consults recommended:
-Social work assistance? Yes, discharge planning and community resources for shelter, rehab programs and AA meetings.
Disposition:
-Need transfer to psychiatry inpatient? No.
Patient does not meet criteria for Baker Act, involuntary hold, or inpatient psychiatric hospitalization. Disposition as per primary team, social work to assist once detox is completed and pt is medically stable.
Unformatted Attachment Preview
Psychiatric SOAP Note Template
Encounter date: 18th/Jan/2024
Patient Initials: Mrs. J Gender: Female Age: 36-years-old Race: Iranian Ethnicity: Persian
Reason for Seeking Health Care: “Chaos in her household and irregular sleeping patterns”
HPI: The 36-year-old Iranian female presented to the clinic complaining about her household
chaos which has also made her to have irregular sleeping patterns. The patient comes to the
clinic accompanied by her 16-year-old daughter for therapy. The patient recently moved to the
United States being an immigrant from Iran with her two children. She got the her visa one year
after staying in the United States and has since then brought her two children to the United States
to stay with her. The patient reports history of trauma due to experiencing domestic violence
from her husband who had been physically abusing her while she was living in Iran. She reports
that her daughter was also sexually assaulted by her father. She states that she feels helpless,
hopeless and overwhelmed by her situation. The patient also notes that her sleeping habits have
been changing and sometimes she is unable to sleep at night. She states that her two children are
now out control. She states that her family has been leaving a traditional lifestyle even though
her children have adopted a different lifestyle and are no longer willing to spend time with her.
She has recently undergone a feet surgery making her currently disabled. She complains of
feeling helpless and lonely as she spends most of her time alone.
SI/HI: Patient has had suicidal ideation
Sleep: She states that she has been having irregular sleeping patterns and for the past one week now she
is unable to sleep at night.
Appetite: She reports continuous decline in her appetite
Allergies: No know food or drug allergies (NKDFA)
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Current perception of Health: Poor
Psychiatric History:
Date
Hospital
Inpatient hospitalizations:
Diagnoses
Decatur Healthcare
Length of Stay
Bone fracture due to traumatic attacks
17 days
th
4 /Dec/2023
Outpatient psychiatric treatment:
Diagnoses
Date
Hospital
28th/Dec/2023
John Hopkins Hospital
Length of Stay
Sleep disorder and depression
3 days
Detox/Inpatient substance treatment: Patient denies
History of suicide attempts and/or self-injurious behaviors: Patient states that she has been
contemplating suicide recently due to her loneliness and disability.
Past Medical History
Major/Chronic Illnesses: Denies
Trauma/Injury: Patient reports being a victim of domestic violence whereby she got a
born fracture from the previous occurrence
Hospitalizations: She had been hospitalized for trauma and bone fracture recently.
Past Surgical History: None reported
Current psychotropic medications:
Antidepressants
Anti-anxiety mediation
Antipsychotic
Current prescription medications:
Escilatopram
Lorazepam
OTC/Nutritionals/Herbal/Complementary therapy: The patient has been using OTC ibuprofen for pain
management
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Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Cigarettes
1 pack
weekly
5-years
Alcohol
2 bottles
Weekly
7 years
Family Psychiatric History: The patient denies family history of psychiatric disorders. She
however states that her dad has dementia and all her other family members are healthy. She
however reports history of sexual and physical trauma from her husband.
Social History
Lives: Single family house without stairs
Marital Status: Married
Education: Completed a vocational certificate
Employment Status: Currently unemployed Current/Previous occupation type: Store
keeper
Exposure to: ETOH and smoke
Sexual Orientation: Heterosexual Sexual Activity: Currently inactive Contraception
Use: Reports the use of morning pills and IUD
Family Composition: Father, mother, and two children
Other: The patient reports that she was born and raised in Iran. She also got married in
Iran and they both moved to the United States with her husband and two children. She
states that her husband has been physically and sexually abusive. She reports history of
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violence which made her to incur a bone fracture. Mrs. J is a Muslim lady married to a
Muslim man and reports that they have been living a traditional lifestyle. Her hobbies
include playing video games and reading novels.
Health Maintenance
Screening Tests: She has never undergone a mammogram or a Pap smear screening
Exposures: Not-reported
Immunization HX: Up-to-date
Review of Systems:
General: The patient appears alert and well-groomed for the occasion. She is cooperative
throughout the exam with clear speck and a
HEENT: The vision and hearing conditions of the patient are all intact. She does not wear
eyeglasses and her ears are also in good condition. Her sense of smell and the buccal cavity are
all intact. The patient has no nasal congestion and throat swelling or irritation
Neck: No neck swelling
Lungs: Denies breathing difficulties
Cardiovascular: Denies dyspnea, edema and palpitations
Breast: No breast lumps
GI: No reflux, abnormal bowel sounds, and abdominal pain
Male/female genital: Denies history of sexually transmitted infections
GU: No abdominal pain. Patient reports normal urine patterns
Neuro: No memory loss, seizures or falls
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Musculoskeletal: Patient recently had a bone fracture which is in the healing process
Activity & Exercise: She reports being physically inactive for the last four months now
Psychosocial: She lives with her husband and two children who have now isolated her due to her
condition. Before the injury, she had been working as a store keeper and she is also a member of
a charity group club.
Derm: She has healing wounds and bruises which she incurred from domestic violence
Nutrition: She has been having challenges with eating healthy foods especially with her current
condition
Sleep/Rest: She reports poor sleeping patterns and insomnia for the past few days
LMP: No pain or lymph node swelling
STI Hx: Patient denies
Physical Exam
BP: 128/79mm/Hg TPR: 98.5F HR: 84 BPM RR: 18 Ht. 5.6’ Wt. 152lbs BMI 22
General: The patient appears alert while lying on the hospital stretcher. She is calm and
cooperative even though at times she portrays anxiety.
HEENT: The patient has good vision and hearing senses. She states that she occasionally
experience headaches which she manages using OTC ibuprofens. She denies throat irritation and
nasal congestion
Neck: No masses on the neck
Pulmonary: No breathing challenges
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Cardiovascular: Denies dyspnea, and palpitations
Breast: No masses on the breast
GI: No abdominal pain or abnormal bowel sounds
Male/female genital: Denies history of sexually transmitted infections. The patient has also had
two normal deliveries
GU: Normal urine patterns without abdominal pain
Neuro: No memory loss, falls, seizures
Musculoskeletal: No history of arthritis or gout but she is nursing a bone fracture
Derm: Healing bruises and wounds
Psychosocial: She has been living with her husband and two children. Her husband was recently
arrested due to the physical and sexual assault cases. Her two children do not like to spend time
with her
Misc. Patient denies
Mental Status Exam
Appearance: Alert, oriented and well-groomed
Behavior: Patient appears to be in distress due to her underlying condition. She is cooperative
during the interview but she easily gets agitated
Speech: Clear
Mood: Euthymic
Affect: Full of range
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Thought Content: Patient reports having suicidal thoughts due to her condition, and loneliness
which has intensified since her two children do not want to spend time with her
Thought Process: Logical
Cognition/Intelligence: The patient is alert, responds to stimuli and appropriately answers
questions
Clinical Insight: No history of hallucinations
Clinical Judgment: Her clinical judgment is fair
Significant
Data/Contributing:
The
patient appears
alert and well-oriented
Dx/Labs/Misc.
She is distressed due to her underlying condition
She easily gets agitated
She reports insomnia for the last few days and change in sleeping patterns
She is a victim of domestic violence and sexual assault
Her daughter who is a minor has also been sexually assaulted by her husband
She reports feeling helpless, hopeless and lonely.
The patient has sudden mood changes involving extreme highs and lows
Plan:
Differential Diagnoses
1. Major depressive disorder
2. Mood and sleep disorder
Principal Diagnoses
1. Major depressive disorder
2. Mood and sleep disorder
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Plan
Diagnosis #1 Major Depressive Disorder
Diagnostic Testing/Screening: Patient Health Questionnaire containing survey questions
Pharmacological Treatment: Antidepressants (Zimmerman et al., 2019)
Non-Pharmacological Treatment: Psychotherapy, lifestyle modification, and social support
Education: Patient should be educated on lifestyle modifications, eating healthy, and
socializing (Thom et al., 2019).
Referrals: Orthopedic
Follow-up: After two weeks
Anticipatory Guidance: Should include the side effects associated with the use of the
antidepressants
Diagnosis #2 Mood and Sleep Disorder
Diagnostic Testingg/Screening: Overnight polysomnography for sleep disorder and
comprehensive history taking for mood disorders
Pharmacological Treatment: Mood stabilizing, sleeping pills, and antidepressant medicines
(Palagini et al., 2019).
Non-Pharmacological Treatment: Psychotherapy, and sleep restriction
Education: Patient should be educated on how to take the prescribed medication. (Meers &
Nowakowski, 2020). She should also be educated on how to change her sleeping habits
Referrals: Orthopedic
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Follow-up: After two weeks
Anticipatory Guidance: She should be guided on how to restrict poor sleeping habits.
Signature (with appropriate credentials):
Cite currently evidenced based guideline(s) used to guide care (Mandatory): see above
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References
Meers, J. M., & Nowakowski, S. (2020). Sleep, premenstrual mood disorder, and women’s
health. Current opinion in psychology, 34, 43-49
Palagini, L., Domschke, K., Benedetti, F., Foster, R. G., Wulff, K., & Riemann, D. (2019).
Developmental pathways towards mood disorders in adult life: Is there a role for sleep
disturbances? Journal of Affective Disorders, 243, 121-132.
Thom, R., Silbersweig, D. A., & Boland, R. J. (2019). Major depressive disorder in medical
illness: a review of assessment, prevalence, and treatment options. Psychosomatic
medicine, 81(3), 246-255.
Zimmerman, M., Martin, J., McGonigal, P., Harris, L., Kerr, S., Balling, C., … & Dalrymple, K.
(2019). Validity of the DSM‐5 anxious distress specifier for major depressive disorder.
Depression and anxiety, 36(1), 31-38.
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Patient Name: Mrs. J
Age: 36-years-old
Date: 21st/Jan/2024
RX: Antidepressants, Mood Stabilizers, and sleeping pills
SIG:
Dispense: _1__________
Refill: _1________________
No Substitution
Signature: ____________________________________________________________
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Psychiatric SOAP Note Template
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SI/HI: _______________________________________________________________________________
Sleep: _________________________________________
Appetite: ________________________
Allergies (Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health:
Excellent
Good
Fair Poor
Psychiatric History:
Date
Date
Hospital
Inpatient hospitalizations:
Diagnoses
Length of Stay
Hospital
Outpatient psychiatric treatment:
Diagnoses
Length of Stay
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Date
Hospital
Detox/Inpatient substance treatment:
Diagnoses
Length of Stay
History of suicide attempts and/or self injurious behaviors: ____________________________________
Past Medical History
• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Current psychotropic medications:
_________________________________________
_________________________________________
_________________________________________
________________________________
________________________________
________________________________
Current prescription medications:
_________________________________________
_________________________________________
_________________________________________
________________________________
________________________________
________________________________
OTC/Nutritionals/Herbal/Complementary therapy:
_________________________________________
_________________________________________
________________________________
________________________________
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Substance use: (alcohol, marijuana, cocaine, caffeine, cigarettes)
Substance
Amount
Frequency
Length of Use
Family Psychiatric History: _____________________________________________________
Social History
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Education:____________________________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual Orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
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Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx,
trauma, violence, social network, marital hx):_________________________________
________________________________________________________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
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Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
GI:
Male/female genital:
GU:
Neuro:
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Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
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Significant Data/Contributing
Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
Principal Diagnoses
1.
2.
Plan
Diagnosis #1
Diagnostic Testing/Screening:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
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Anticipatory Guidance:
Diagnosis #2
Diagnostic Testingg/Screenin:
Pharmacological Treatment:
Non-Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
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DEA#: 101010101
STU Clinic
LIC# 10000000
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)______________________________
Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
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