[SAMPLE SOLUTION] Psychiatric-Focused SOAP Note
Patient: DD Age: 66 Sex: Male Race: Caucasian
SUBJECTIVE:
Chief Complaint: Psychiatric evaluation to determine the need for psychotropic medication management
History of present illness:
DD is a 66-year-old Caucasian male who presented to the hospital for a psychiatric evaluation. DD reports social anxiety, where he finds trouble talking or interacting with large groups of people. He says that he only gets confident after taking alcohol. DD also reports migraines. DD also reports not believing in God anymore, although he was raised a catholic. DD was on Vyvanse long ago but stopped because it was not working. DD is currently on Zoloft 150 mg daily
PMH:
No reports of significant illness
Accidents/Injuries:
No major accidents or injuries
Hospitalizations:
No reports of hospitalization
Surgeries:
No surgical history
Current medications:
Zoloft 150 mg daily orally
Immunization Status:
Up to date on all immunizations, last Tdap: 21/6/2020
Allergies:
NKDA, no allergies to food and environment
Social History:
The patient is married, has two daughters, and lives with his family. The patient is retired, although he did a presentation about IT issues to a large group of people.
Reported taking alcohol but stopped some time back and never smoked
Family History:
The patient’s father was diagnosed with a social anxiety disorder at the age of 30 and died at the age of 68 from an accident. The patient’s mother showed symptoms of bipolar disorder, although this was ruled out using the Bech-Rafaelsen Mania Rating Scale (MAS). No significant illness in the family history
Mental state examination (MSE):
Appearance and Behavior:
The patient was well-groomed. However, he appeared nervous and tensed and could not maintain eye contact during the examination.
Speech:
The patient exhibited normal spontaneous speech with no halting or fumbling.
Mood:
The patient’s mood was normal initially, but he panicked and became restless as the examination continued. He declined to answer some questions
Thought and perception:
Although the patient harbored realistic concerns, he would sometimes express fear when normal questions were asked
Cognition:
The patient appeared conscious and oriented. However, he had difficulty concentrating.
Insight and Judgment:
The patient knows his mental condition, what triggers it, and how to manage it. The patient, therefore, engages in activities that reduce his social anxiety
Differential Diagnoses:
Social anxiety disorder (F40.10)
Bipolar 1 (F31.12)
Major depression with social withdrawal (F33.0)
Generalized anxiety disorder (F41.1)
Signs and Symptoms:
Social anxiety disorder
This is characterized by extreme fear in social settings with fear of being scrutinized or judged by people (Leichsenring & Leweke, 2017).
Bipolar 1
This is characterized by mood swings ranging from manic highs to depressive lows (Tondo et al., 2017). These events are not associated with fear of social settings.
Major depression with social withdrawal
This is described by avoidance of social interactions due to persistent sadness and loss of interest (Greer & Joseph, 2019). Although the patient avoids social interactions, the reasons are not due to fear of being judged or scrutinized by people, as in the case of social anxiety disorder.
Generalized Anxiety Disorder:
This is characterized by restlessness, continuous worry, poor concentration, irritability, and difficulty falling or staying asleep (Huang & Zhao, 2020). Although a social anxiety disorder also exhibits these symptoms, the situations leading to a generalized anxiety disorder are majorly multiple issues unrelated to social situations.
Client’ Progress: N/A
Patient’s Stated Goals:
The patient wants to learn other safe means of
Order this paper