MN660 Case Study Psychiatric SOAP Note and Rx Template
Do you need help with your assignment ? Contact us at eminencepapers.com.
| Criteria | Clinical Notes |
| Subjective | The patient is a 26-year-old male presenting for consultation because of pending legal issues regarding drunk driving. He thinks that his psychiatric symptoms are the likely causes of his conduct. His psychiatric history reveals that he has experienced major depressive episodes but is currently euthymic. His depression often presents with insomnia, depressed mood, despondent thoughts, impaired cognition, and poor energy. The patient notes that his self-esteem drops and that he experiences a feeling of guilt for no reason. He is also sensitive to rejections. The patient denies having suicidal thoughts. His past medical history reveals that he has had major depressive episodes of varying severity and lengths since his teenage, most of which were untreated. His depressive episodes have been incapacitating, often interfering with his schooling and work. He, however, has had a good inter-episode recovery as he has been able to return to work and class after depressive episodes. He also has anxiety symptoms. He feels nervous around people, experiences anticipatory anxiety, and will try and avoid certain social events. His medication history reveals that he had been started on a selective serotonin reuptake inhibitor for the management of generalized anxiety disorder (GAD) and depression. The medications elevated his mood within days. The medications also alleviated the symptoms of avoidance, fear, and anxiety. He was, however, unusually talkative, was easily distractible, had racing thoughts, was impulsive, hyperactive, had a lowered need for sleep, and exhibited grandiosity. He felt invincible and that the law did not apply to him. The social history of the patient is positive for heavy alcohol use. He has completed college and has friends in his immediate neighborhood. He has no family history of bipolar disorder. However, his mother has GAD. The patient is currently not taking any medications.
Review of systems negative with the exception of the cardiovascular system, where the patient reported having experienced palpitations in some instances. |
| 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, Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”. | |
| Objective |
The patient has a BP of 160/80, a pulse rate of 76 beats per minute, and a respiratory rate of breaths per minute. The patient is alert and oriented to place, time, and event. He seems restless and fatigued. He answers questions asked appropriately and maintains eye contact. Examination of the cardiovascular system reveals notable palpitations. The patient is at high risk of self-harm and is accustomed to his grandiose state and disinhibition. His current legal battle with drunk driving is a manifestation of his antagonism to social order.. |
| This is where the “facts” are located. Include relevant labs, test results, vitals, and physical exams if performed. Include MSE, risk assessment here, and psychiatric screening measure results. | |
| Assessment | Assessment finding reveals that the patient has a history of major depressive disorders and anxiety episodes. The differentials, in this case, include generalized anxiety disorder, major depressive disorder, bipolar disorder, substance abuse disorder, schizophrenia, and psychosis. Psychosis, schizophrenia, and substance abuse disorder are highly unlikely in this case as they are not supported by the findings.
The clinical diagnosis in this patient’s case is bipolar disorder (ICD-10 code F31). His manifestations are consistent with the bipolar symptoms described in the DSM-5. As per this diagnostic manual, bipolar disorder is characterized by alternating episodes of mania or hypomania and depressive episodes. The patient in the case has a history of major depressive disorder and generalized anxiety. His history also revealed medication-induced mania as evidenced by risk-taking, a feeling of invisibility, racing thoughts, high energy level, decreased need for sleep, talkativeness, and restlessness after taking selective serotonin reuptake inhibitors. These symptoms are aligned with those of bipolar 1 disorder. The treatment options available for the patient include pharmacotherapy to manage the manic and depressive episodes of the disease and other non-pharmacological interventions such as cognitive behavioral therapy and electroconvulsive therapy. The patient is currently not taking any medication. He is open to all therapeutic suggestions. His legal issues may, however, affect his adoption of therapeutic interventions such as cognitive behavioral therapy as they require more time and a systemized approach in their execution. Medications may be appropriate as they are easier to monitor and may be used in outpatient settings. |
| 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 | Comprehensive management of bipolar disorder utilizes pharmacotherapy to manage manic and depressive phases. The patient on the case will be started on sodium valproate 500mg every 12 hours for the maintenance treatment of his disease. The patient will also be advised to report to the clinic for evaluation whenever he feels depressed.
Mood stabilizers such as sodium valproate and lithium are the first-line agents in the management of the manic phase of bipolar disorder (Yalin & Young, 2020). They maintain effectiveness in de-escalating distress, stabilizing the patient, and mitigating potentially harmful and risky behavior. These medications are often initiated at low doses and then titrated upwards per the patient’s response. Patient monitoring and education are necessary when using sodium valproate and lithium. Benzodiazepines may also be used adjunctively with mood stabilizers in the management of mania. Bipolar depression can be managed with antidepressant medications. First-line agents include olanzapine and quetiapine. These medications maintain effectiveness in elevating the mood of the patients. Patients may also benefit from non-pharmacological interventions such as cognitive behavioral therapy. These interventions are used adjunctively with pharmacotherapy and are seldom used as monotherapy in the management of bipolar depression. The patient is scheduled for clinic re-visitation after two weeks. He may be referred for further psychiatric care in case he experiences multiple depressive episodes.
|
| 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. |
ORDER A PLAGIARISM-FREE PAPER HERE
We’ll write everything from scratch
Question 
Use this SOAP Note and Rx template to complete the Case Study. There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note.
MN660 Case Study Psychiatric SOAP Note and Rx Template
This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting.
Complete the order form and upload all of your files, including any instructions, rubrics, or other materials provided by your instructor. 
Complete the order payment after filling in the order form. We’ll receive your order and assign it to a writer.
The assigned writer will complete your paper and forward it to our Editing Team for review and approval.
Once approved by the editor, the completed paper will be uploaded to your account for you to download, review and approve.