Description
-Chief Complaint: “I have a crazy boyfriend”
History of Present Illness:
Per EHR review: “This is a 48 years old white Hispanic male with a past medical*HIV, chronic hepatitis C, depression, history of lumbar surgery, and history of seizures. Patient noncompliant with his medication. Patient was brought to the ER by the police because he got arrested due to domestic violence and patient in police car started hitting his head on the windshield and by police patient started having seizure-like activity for like 10 seconds. Patient also have seizures while he was in the ER. Patient seen by neurology. He did receive loading dose of Keppra. His medication was changed for a Vimpat 100 mg twice a day loading dose was given. And by neurology recommendation patient should be admitted to the hospital for observation for seizures. Patient postictal, but answer the question. Denies chest pain palpitations, denies any abdominal pain, nausea, vomiting, fever or chills.”
C-L psychiatry is consulted for management of depression.
Patient was seen and evaluated at bedside, accompanied by corrections officers. AAOx3, calm and cooperative. Patient reports that he got into a domestic dispute with his partner of 5 years in which he ended up getting arrested. Patient reports that he has had multiple physical altercations with his partner and his partner has a restraining order against him; he reports officer told him to come to the car and put his hands on the hood and he refused and began running. Patient is complaining of severe depression, helplessness, hopeless, low self- worth, poor sleep, poor appetite and passive SI. Patient reports he has no clear plan, but his life is not worth living if he has to go on like this. Patient has been non-compliant with psychotropic medications for the past year and reports not being able to remember any of the medications that he has taken in the past. Patient is amenable to starting an anti-depressant and following up in the community upon discharge from jail.
-Diagnoses: MDD, Cocaine Use Disorder, Alcohol Use Disorder, Marijuana Use Disorder, Nicotine Use Disorder
-Past Hospitalizations: multiple
-Outpatient: non-compliant
-ECT: no
-Psychiatric Medications: per chart- Cymbalta 20mg PO BID
-Past suicide attempts: reports x’s3, last attempt 1 year ago via hanging, reports he received care at Aventura Hospital
-Past violence: yes, multiple arrest for violent behavior
Past Substance Use history:
-Substances: hx of alcohol use- denies current use and cannot quantify previous amounts
hx of marijuana use- denies current use, however DAU +
hx of nicotine use- denies current use
hx of crack cocaine use- denies current use
-Past Marchman Act: denies
-Past Detox/Rehabilitation: denies
-AA/NA Participation: none
-Past Medical Complications: as per chart review
Family History:
Grandmother- unknown mental illness
Past Medical History:
-Medical diagnoses: reviewed
-Surgeries: reviewed
-Allergies: iodine
Social History:
-Born and raised: New Jersey
-Relationship Status: Single
-Children: none
-Education: high-school
-Employment: disabled
-Living situation: alone
-Hx of trauma: Yes, IPV
-Orientation: Ox3
-Appearance and Behavior: 48 y/o man, appears stated age, disheveled and unkempt, shackled to bed, cooperative
-Motor/Gait: no abnormal movements
-Eye Contact: good
-Speech: coherent
-Mood: “I’m very depressed”
-Affect: dysphoric
-Thought Process: tangential
-Thought Content: pre-occupied with arrest and partner
-Perceptual disturbances: no a/v/t hallucinations illicited
-Suicidal thoughts/Intent/Plan: passive death wishes
-Homicidal thoughts/Intent/Plan: denies
-Insight: limited
-Judgement: limited
-Attention: good
-Concentration: good
-Memory: impaired
-Language: English
-Fund of knowledge: baseline for level of education
Diagnoses
MDD, recurrent, by hx
Cannabis Use Disorder
Alcohol Use Disorder, by hx
Nicotine Use Disorder
Abrasion of scalp, initial encounter (S00.01XA)
Unspecified convulsions (R56.9)
End of Diagnoses List
Psychiatric Consult Recommendations:
Medication recommendations:
Start Effexor 37.5mg PO daily- depression, anxiety and chronic pain
Zyprexa 5mg IM q6hrs PRN- severe agitation that impedes medical care.
Labs/Imaging recommendations:
reviewed
qtc 428
dau + cannabis
Safety:
-At risk of harm to self or others: No
-Needs 1:1 sitter: No
-Requires video monitoring: No
-Baker Act status: None
-Marchman act status: No
Precautions:
-Fall risk: No
-Seizure: Yes
-Elopement: Yes
-Suicide: No
-Substance use withdrawal: Yes
-Delirium precautions: No
Other consults recommended:
-Social work assistance? Yes, safe transport to TGK jail psychiatric unit.
-Other recommended consults? No
Disposition:
Does not meet criteria for inpatient psychiatry hospitalization or involuntary hold. Discharge plan as per primary team.Patient is psychiatrically clear to be discharged to jail.
Unformatted Attachment Preview
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
Rev. 10162021 LM
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:
_________________________________________
_________________________________________
________________________________
________________________________
Rev. 10162021 LM
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: _____________________________
Rev. 10162021 LM
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:
Rev. 10162021 LM
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:
Rev. 10162021 LM
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Mental Status Exam
Appearance:
Behavior:
Speech:
Mood:
Affect:
Thought Content:
Thought Process:
Cognition/Intelligence:
Clinical Insight:
Clinical Judgment:
Rev. 10162021 LM
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:
Rev. 10162021 LM
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)_______________
Rev. 10162021 LM
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: ____________________________________________________________
Rev. 10162021 LM
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