Psychiatric SOAP Note Template
Encounter date: ______17/05/2023__________________
Patient Initials: ___G.W.___ Gender: M/F/Transgender _Male___ Age: __15___ Race: ___Caucasian__ Ethnicity __White__
Reason for Seeking Health Care: “For the past three weeks, my son has been quite depressed. He has not been eating well and prefers to spend his after-school hours alone in his room. He used to like swimming, but now he does not appear to want to. I worry that he might have a medical issue.”
HPI: _____ __The patient is a 15-year-old boy who is brought to the clinic by his concerned mother. The patient's mother admitted that the symptoms, which began three weeks ago, coincided with the beginning of a new school term. The mother admitted that the patient has been extremely sad and has expressed constant feelings of hopelessness and worthlessness. The mother also admitted that the patient has also had a decrease in appetite, which has resulted in the loss of a couple of pounds. The mother also admitted that the patient has been complaining of difficulty falling asleep as well as disrupted sleep patterns, which often have him waking repeatedly during the night. The mother reported that, as a result of a lack of sufficient sleep, the patient often looks fatigued and lacks energy during the day. The mother also reported that she has noticed a drop in his social interactions, often preferring to spend long periods alone in his room. The mother also admitted that the patient has also lost interest in any extracurricular activities, including swimming, which he used to enjoy doing. The mother admitted that she noticed that the symptoms worsened during stressful situations, such as exams or social events. The mother admitted that the symptoms are persistent, however, even when he is relaxing. The mother admitted that on a scale of 1 to 10, the severity of his symptoms is 7/10. The mother denied that the patient was taking any over-the-counter or prescription medication. ______________________________________________________________________________
SI/HI: ________The patient admitted that he had been experiencing recurrent suicidal ideations. He denied having attempted suicide. _______________________________________________________________________
Sleep: _________ The patient admitted to having difficulty falling asleep as well as disrupted sleep patterns. __ Appetite: ____ The patient admitted to a decreased appetite as he does not feel like eating ____________________
Allergies (Drug/Food/Latex/Environmental/Herbal): The mother admitted that the patient has a severe allergy to peanuts, which results in immediate itching, and swelling of the face, lips, and throat. The mother admits that the reaction necessitates medical attention and that the patient carries an epinephrine auto-injector at all times. _
Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
|
Date |
Hospital |
Diagnoses |
Length of Stay |
|
None |
None |
None |
None |
|
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 having had a history of suicidal attempts, however, he admitted to having a history of self-injurious behavior whereby he repeatedly bit himself on his arms, which resulted in marks on the skin.
Past Medical History
· Major/Chronic Illnesses __ The mother denied the patient has a history of major or chronic illnesses _______________________________________________
· Trauma/Injury ___ The mother admitted that the patient has in the past been a victim of physical assault from bullies in his school which resulted in several bruises. ________________________________________________________
· Hospitalizations __The mother denied the patient having a history of hospitalizations. ________________________________________________________
· Past Surgical History ___ The mother denied the patient has any history of a surgical procedure performed on him. ______________________________________________
Current psychotropic medications:
___________None______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Current prescription medications:
____________None_____________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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 father who is currently 45 years old has a history of generalized anxiety disorder and social anxiety disorder which he manages with antipsychotic medications and occasional psychotherapy.
· The patient's older brother, who is currently 19 years old, was diagnosed with attention-deficit/hyperactivity disorder when he was 7 years old and has been taking stimulant medications under the supervision of a psychiatrist. He is also engaging in ongoing behavioral therapy to manage his symptoms.
· The patient's 70-year-old maternal grandmother has a history of major depressive disorder and has been getting antidepressant medication and regular therapy sessions for some time.
· The patient's paternal uncle, who is currently 54 years old, has a history of bipolar 1 disorder. He has been experiencing episodes of both manic and depressive symptoms over the years and has been receiving treatment with mood stabilizers and regular psychiatric follow-ups to manage his condition.
Social History
Lives: Single-family House/Condo/ with stairs: ___5-bedroom apartment________ Marital Status: __Single_____
Education: ________10th grade student____________________
Employment Status: __Unemployed____ Current/Previous occupation type: _____None____________
Exposure to: _Denies_ _Smoke__ Denies__ ETOH __Denies __Recreational Drug Use: __________________
Sexual Orientation: __Homosexual_____ Sexual Activity: __Not active__ Contraception Use: ___None_________
Family Composition: Family/Mother/Father/Alone : ___The patient lives with his mother, father, and his older brother. __________________________
Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): _____
The patient was born in a small town in Minnesota. He grew up in a stable household as both his parents are supportive and nurturing. Currently, he resides with his parents and older brother in a suburban neighborhood. The patient used to enjoy spending his free time engaging in swimming and painting. He is also an avid reader and loves exploring different genres of literature.
Health Maintenance
Screening Tests:
· The patient underwent vision screening on November 5, 2023, the results revealed a visual acuity of 20/20 in both eyes.
· The patient underwent height and weight measurements on January 10, 2023. The results revealed that he had a height of 5 feet 8 inches and a weight of 145 pounds which was within the normal range.
· The patient underwent cholesterol screening on the 10th of January 2023. The Results revealed that his total cholesterol level was 165 mg/dL which was within desirable range.
· The patient undergoes dental checkups every 6 months with the last checkup on the 5th of November 2022. The results were negative for signs of cavities or dental issues identified.
Exposures: The patient's mother denies the patient being exposed to any chemicals, including secondhand smoke or ethanol.
Immunization HX:
The patient is currently on all his immunizations, including tetanus, diphtheria, and pertussis (Tdap) booster and the HPV (human papillomavirus) vaccine.
Review of Systems:
General: The patient's mother admitted to the patient having significant weight loss, fatigue, decreased energy levels, a lack of motivation, and difficulty falling asleep.
HEENT: The patient's mother denies head trauma, dry scalp, or loss of hair. She denies the patient having any visual disturbances, eye injuries, or infections. She denied the patient having any hearing problems or earaches and admitted to occasional middle ear infections when he was younger. The mother admitted the patient has occasional nose bleeds, a runny nose, and a congested nose. The mother denied the patient having mouth sores, bleeding gums, missing teeth, or cavities.
Neck: The patient denies any neck pain, stiffness, or swollen glands.
Lungs: The patient denies any shortness of breath, cough, or wheezing.
Cardiovascular: The patient denies any chest pain, palpitations, or irregular heartbeats.
Breast: The patient denied any breast or nipple injury, enlargement of the breast, or breast pain
GI: The patient denies any abdominal pain, nausea, vomiting, or changes in bowel habits. However, the patient’s mother admitted to the patient having a loss of appetite and unintentional weight changes.
Male or female genital: The patient denies any genital pain, penile discharge, or lesions.
GU: The patient denies any urinary frequency, urgency, or burning sensation during urination.
Neuro: The patient denies any history of seizures, tremors, or loss of consciousness. However, the patient admitted to difficulty concentrating and a general feeling of being slowed down.
Musculoskeletal: The patient denies any joint pain, swelling, or muscle weakness. However, the patient mentions feeling physically fatigued.
Activity: Exercise: The patient reports decreased interest in activities previously enjoyed, such as swimming, and a significant reduction in physical activity.
Psychosocial: The patient admitted to feelings of sadness, hopelessness, and social withdrawal. The patient also admitted to having suicidal thoughts and self-injurious behaviors.
Derm: The patient denies any skin rashes, itching, or the appearance of moles. He admitted to occasionally having several pimples on his forehead.
Nutrition: The patient's mother admitted that the patient has been experiencing a decreased appetite and unintentional weight loss.
Sleep/Rest: The patient admitted that he has been having trouble falling asleep, and frequent awakenings during the night, and early morning awakenings.
LMP: Not applicable as he is a male patient.
STI Hx: The patient's mother denies the patient having any history of sexually transmitted infections, penile infections, or urinary tract infections.
Physical Exam
BP____118/76 mmHg taken while the patient was in a seated position____TPR___96F taken through the mouth__ HR: ___82__ RR: _19__Ht. __172 cm___ Wt. __56 kg____ BMI ( percentile) ___18.9 kg/m2 (35%, Healthy weight) Pain: No pain reported at this time
General: The 15-year-old boy appears clean with no odor; he appears thin and pale, with a lack of energy, and looks sad.
HEENT: He has a head that is normocephalic and free of lesions, spots, or lumps, no signs of hair loss, and a homogeneous distribution of hair on his head. He has dark circles under his eyes, indicating poor sleep patterns, he has no eye discharge, equal, rounded pupils that react to light appropriately; he avoids eye contact; and he appears downcast.
Neck: There is no palpable lymphadenopathy or swelling in the neck, and there is no evidence of thyroid enlargement or tenderness. A complete range of motion in the neck is observed.
Pulmonary: No shortness of breath; rapid breathing even with minimal exertion. Cough, abnormal breath sounds upon auscultation, or reports of a history of asthma or respiratory infections.
Cardiovascular: There is no peripheral edema or noticeable redness in the extremities. No chest pain, heart rate, and rhythm are regular and there are no abnormal heart sounds upon auscultation.
Breast: No breast abnormalities are observed, no palpable masses or tenderness, nipple discharge, changes in breast size, or signs of gynecomastia or breast asymmetry.
GI: There is no evidence of abdominal distention or tenderness, a report of changes in bowel habits, or gastrointestinal bleeding. No stomach aches or ongoing nausea was observed. Report of a significant decrease in appetite, leading to weight loss.
Male/female genital: No abnormalities are observed in the external male genitalia. No pain or discomfort in the genital area, penis discharge, or lesions present. There was no report of difficulty achieving or maintaining an erection.
GU: No pain or discomfort during urination. There is no report of a decrease in urinary frequency or urgency. There was no visible blood or abnormal color in the urine.
Neuro: Cranial nerves 2–12 were undamaged, and muscle strength was 5–5. Exhibits poor concentration and a diminished ability to recall the information observed. Speech is slow and lacks enthusiasm. No focal neurological deficits or abnormal reflexes were observed. No seizures or head injuries.
Musculoskeletal: No muscle aches and joint pains, no joint swelling or visible deformities, full range of motion in all joints. No reports of fractures or significant injuries noted
Derm: Dry, pale skin with a lack of luster was observed. No itching or scratch marks were observed. Faded bite marks on both arms were observed. No visible rashes, lesions, or discoloration.
Psychosocial: The patient is conscious and cognizant of the time, place, and persons. He appears to have a persistent low mood, he expresses signs of hopelessness and a desire to isolate himself from friends and family, preferring to spend time alone. He has difficulty expressing his emotions and often keeps his thoughts and feelings to himself.
Misc. N/A
Mental Status Exam
Appearance: The patient's appearance was clean, with slightly unkempt hair and no noticeable body odor. He avoided making eye contact and had a slumped posture.
Behavior: The patient exhibited withdrawal behavior and displayed psychomotor retardation, with slowed movements and minimal facial expressions. The patient frequently sighed and displayed a lack of energy.
Speech: The patient spoke in a monotone tone with little variety. He spoke awkwardly and slowly, pausing a lot in between sentences. He constantly made jokes about himself and admitted to feeling unworthy. The patient often talked about feeling hopeless and having suicidal thoughts.
Mood: The patient was constantly gloomy and had a downcast attitude. He claimed to feel helpless, burdened, and dejected about the future. The patient reported having ongoing depressive symptoms and losing interest in activities. He talked of being disconnected from himself and incapable of enjoying himself.
Affect: The patient had a flat, dull affect. He had a limited range of facial expressions and showed little emotional expressiveness. The patient's emotional state remained rather constant throughout the dialogue and lacked acceptable emotional reactions.
Thought Content: The majority of the patient's thoughts were negative and self-deprecating. He constantly felt guilty and blamed himself. The patient constantly stated that he felt like a burden to others and often entertained ideas of committing suicide.
Thought Process: Overthinking and uncertainty marked the patient's way of thinking. He struggled with concentration and frequently became distracted during conversations. The patient constantly skipped from one subject to another for no apparent reason. He had a negative and warped way of thinking.
Cognition/Intelligence: The patient's cognitive functioning appeared intact. He was able to provide accurate details about his personal history, including his educational background and family relationships. He demonstrated adequate comprehension and understanding during the assessment. No significant impairments in memory or problem-solving skills were observed.
Clinical Insight: The patient had limited clinical insight into his condition. He attributed his symptoms solely to external circumstances, such as his being homosexual.
Clinical Judgment: The patient's clinical judgment was impaired due to his depressive symptoms. He showed limited ability to evaluate the consequences of his actions and had difficulty making decisions. The patient expressed feelings of hopelessness and helplessness regarding his future, which affected his ability to consider alternative courses of action.
PHQ-9 score of 17 indicated moderately severe depression symptoms
Complete Blood Count (CBC): The CBC revealed negative for any abnormalities, with all blood cell counts within the acceptable range.
Thyroid Function Tests: The thyroid function tests, including TSH of 2.0 mIU/L. and T4 of 8.0 μg/dL.indicated normal levels of thyroid function.
Significant Data/Contributing Dx/Labs/Misc.
Plan:
The PHQ-9 (Patient Health Questionnaire-9)
