Major Depression, Recurrent? 2. Schizophrenia, Paranoid? 3. Panic Disorder versus Thyroid Medication Overuse? 4. Hypothyroidism with Depression? 5. Bipolar Disorder (

Florida National University

PMHNP PGC

Typhon Soap Note Rubric
Criterion	Description	Present	Not Present
	Subjective
Client identifying information. 5 points	age, marital status, general appearance, reliability, ethnicity (state at end of scenario, in case formulation).
Chief Complaint 5 points	“in patient’s own words” reason for visit-restate in case formulation.   e.g. R presents in this initial outpatient appointment alone, for evaluation and management of: (insomnia).
History of Present Illness 5 points	(Why present now/precipitants/stressors? When it started? How long it lasts/frequency? What is it like? Impact on life) Neurovegetative Symptoms: Sleep Appetite and weight Energy Concentration Anhedonia Mood Diurnal variation of mood SI/HI Anxiety-all disorders Mania Psychosis Sexual interest/performance Must include chronological timeline of development of current problem, what they have tried to help the problem, assessment of strengths and usual coping strategies. Include any medications tried with responses.
Risk assessment: suicide/violence 5 points	Ask about any homicidal ideation – and first experience of suicidal ideation, and any history of attempts. Assess if ever had feelings of hopelessness
Psychiatric History 5 points	Ask at what age first saw a counselor or psychiatrist.  Ask about first time taking psychotropic medications, and obtain chronological history with medications, duration and response – helpful or side effects, with reason for discontinuation.
Substance Use History 5 points	This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures. For reporting substance use, include age of first use, date of last use, frequency, amount and method. of use
Past Medical History: 5 points	Does patient obtain primary care? Date/name of provider and last visit.  List any chronic illness. with date of dx and treatment regimen. Allergies. Current medications.
Family History:  5 points	Inquire about family history of any psychiatric problems – depression, anxiety, substance use disorders, psychiatric hospitalizations, suicide attempts.  Prompt to inquire about parents, grandparents, aunts or uncles, siblings and their children if applicable.
Personal History 5 points	Place of birth: As a child: (family structure, parents’ occupations, relationship with parents, siblings, friends, abuse) As a teen: (friends, relationships, school, activities, sex, trouble, relationship with parents) As an adult: (work, finances, education, relationships, family, goals for future, trends in functioning)
Psychosocial 5 points	History: Inquire about religion/spiritual beliefs, sexuality, living situation, education, employment. history of incarceration, current support systems, hobbies, activities of interest, talents
Education 5 points	No formal education  Elementary school completed. Some high school-did not graduate. High school graduate College graduate
Employment: 5 points	Unemployed Employed on Disability
Developmental 5 points	History: Inquire about mother’s pregnancy and delivery, childhood with attainment of milestones, any learning disabilities or academic problems.
Psychiatric Review of Systems: 5 points	Has patient ever experienced depression, anxiety, mania, ADHD, OCD, eating disorder, psychosis, trauma, personality disorder ? Medical Review of Systems: especially history of seizure or head trauma
	Objective
Mental Status Examination: 5 Points	Appearance  Behavior  Speech  Mood(inquired) Affect (observed) Thought process (observed) Thought content (inquired)  Cognition (inquired – include memory/ recall)  Insight/Judgment (Some areas are observed, and some are inquired – describe all areas observed in Case Formulation) Assets/strengths Liabilities Do full MMSE if memory concerns or over age 65 (score 1-30)
	Assessment
Impression formulation 5 Points	e.g. The patient is a 36-year-old Caucasian male with a long history of depression and attention deficits. Hyperactivity criteria are essentially absent. Although medications have been somewhat efficacious, he has residual symptoms that are quite troublesome
Diagnosis 10 Points	Diagnoses Medical diagnoses Differential diagnoses: (generally is the medical causes of the symptoms, such as hypothyroidism or brain tumor, for example) Rule out diagnoses: (generally refers to DSM 5 diagnoses that you suspect and will continue to evaluate for; e.g. if someone has MDD, then one R/O is Bipolar II Disorder, Most Recent Episode Depressed) DSM-5 criteria: (what criteria are met, what criteria are not met at this time; how arrived at decision re the diagnosis)
	Plan
Plan 10 Points	Labs/ Diagnostic Tests/ Screening Tools Medications Dosage & directions Why this med? Neurochemistry & MOA Side effects Expected benefits Contraindications Black Box Warnings Therapy prescription Type(s), duration, etc Why this therapy? Expected benefits Therapy goals Teaching plan Safety plan Diet and exercise Sleep Stress management/set goals/ homework Health promotion Relationship issues Resources (bibliotherapy, websites, etc)Teach about meds, side effects, caution Other Referrals and consultations PCP for physical exam or other follow up for symptoms Psychoneurological assessment (eg. child with learning disorder) Outpatient substance abuse treatment, etc Inpatient hospitalization Follow up Time frame for next appointment based on assessment, safety

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SOAP Note: 48-year-old Hispanic Female with Depression with Psychotic Features Roxana Orta

Florida Atlantic University

( Running Head: DEPRESSION WITH PSYCHOTIC FEATURES ) ( 1 )

SOAP Note: 48-year-old Hispanic Female with Depression with Psychotic Features

IDENTIFYING DATA

MM is a 48-year-old, divorced, a Hispanic female who was brought to the clinic by her son after been discharge two days ago from a crisis unit after an episode of psychosis.

CHIEF COMPLAINT

“Feeling that the FBI is following me, and my parents want to poison me."

FAMILY HISTORY

Patient reports that her 67-year-old mother was born in Cuba, she emigrated to the United States a year ago with her father. Her mother completed high school, and is not currently working; she does not speak English and relies solely on the patient's income for support. Mother does have a history of hypertension and rheumatoid arthritis, also reports a history of depression, which the patient's called "un Estado de nervios." Patient's 69-year-old father completed high school and worked as a mechanic in his native country, and he is not currently working because he is waiting for his work permit. He has a medical history of hypertension, obesity, and benign prostate hypertrophy. Patient's father does not have an account of substance or mental health problems. However, he smokes a pack of cigarettes daily. A patient has one sibling, a younger sister who was still living in Cuba; her sister is healthy and has no history of substance abuse or mental health problems. The patient also reports that in her mother side, two of her aunts suffered from postpartum depression, as well as one of her cousins. She also states that two of her uncles were alcoholic. In her father side, the patient reports a history of substance abuse by two of her paternal uncles.

( DEPRESSION WITH PSYCHOTIC FEATURES ) ( 10 )

PERSONAL HISTORY

Patient reports having no birth issues, she was born a standard delivery, full term, and with no complications. The patient also reports completing all the milestones, doing well in school. She states that the only issues growing up were her father incarceration for ten years as a political prisoner, which was very traumatic, and she became very fearful after that. Since that time, she has never been able to speak up her mind. She states," I rather don't say anything, even when I know it is not right."

MEDICAL HISTORY

The patient does not have health insurance, and the last time she saw a physician was when she did physical for her employment. Her immunizations are up to date, and she does not have either a food or medication allergy. She has a history of endometriosis, what she states, “it resolved in her mid-thirties." She also injured her back a year ago, and she said that she received injections, but she does not know the name of the medication. She denies any other problems, except for occasional cold and sore throat. Which is treated with over the counter medications. Otherwise, she has never hospitalized, except during childbirth, which was standard delivery. Currently, the patient is taking multivitamins and sleepy time tea. She has not had a mammography or PAP smear in the last five years. Her laboratory results show microcity anemia and slightly elevated

LDL. Laboratory results on admission to her hospitalization included thyroid-stimulating

hormone, and thyroxine were all within reasonable limits. Her blood pressure and weight are within normal limits.

SOCIAL HISTORY

Patient shares a two-bedroom apartment with her mother and father. She reports been married for two years to the father of her son. Since that time, she has not had any romantic relationships or sexual relationships because her life was dedicated to her son. She has no friends currently, only some coworkers whom she frequents. Patient states, “I work from 7 AM to 11 PM, I have to support my family, I have no time for friends”, She denies having any hobbies or interest. She enjoys watching Spanish television. She does not smoke, drinks alcohol, or consume any illegal substances. Patient denies any history of legal problems. Patient only son is a 19-year-old college student who accompanies the patient to this evaluation. She reports having a great relationship with her son and that his living to school has been very hard on her.

OCCUPATIONAL HISTORY

The patient is a high school graduated, with no history of military service, and has a nursing assistant certificate. She has two jobs, and she states," the situations are very demanding, I have two expend most of the time bathing patients and feeding them.” I have been working steadily for the past two years without a vacation or a weekend off”. Patient reports that due to her recent hospitalization, she has reduced her work hours to 40 hours a week.

PAST PSYCHIATRIC HISTORY

Patient denies any history of outpatient or psychiatric hospitalization before the admission described above. She was discharged two days ago from the crisis unit. She was started in Risperdal 2 mg. At bedtime, Trazodone 100 mg PO HS, and citalopram 20 mg. In the AM. Patient reports having an episode of depression right after the birth of her son, she denies having any treatment or follows up for the incident. She states” after giving birth to my son, I felt sad,

tired and had weird thoughts, for months I did not feel any happiness, it lasted about two years, then it went away." No history of suicidal or assaultive behavior.

HISTORY Of PRESENT ILLNESS

Patient reports feeling nervous since her son left for college back six months ago. In the last three months, her sleep deteriorates to the point that she was only sleeping for two or three hours at night.Two weeks ago, after working in the night shift, she thought that people were following her, she saw lights everywhere and became very frightened. She also reports at that time starting hearing voices telling her that the FBI was after her. The patient also has lost about 10 pounds, because she believed that her parents want to poison her. She states," I was so scared that I decided to drive my car against a tree." Patient reports that the symptoms were so frightening that she stopped her car in the middle of the road and asked a policeman for help. Son says that his mother has been experiencing lack of sleep and mood swings since moving to the United States about five years ago. Son reports his mother works all the time, and that at times she becomes irritable and distant. PHQ-9 was administered, and her score was 25, which indicates "severe depression.”

PSYCHIATRIC REVIEW OF SYSTEM:

a) Anxiety: Anxious, worried, feeling restless, and experiencing muscle tension.

b) Mania: Patient denies periods of increased energy. However, she reports feeling irritable

most of the time.

c) Depression: Reports feeling of sadness and loneliness, unable to concentrate, with lack of

appetitive, sleepless, and with no motivation of joy about anything, she states feeling guilty

about getting sick, she is worried about her parents and son, no pleasure in activities, having

problems with sleep and having issues with eating. Trouble is concentrating most of the days

and having suicidal thoughts. She reports feeling hopeless.

d) Schizophrenia: patient reports hearing command hallucinations. She denies visual

hallucinations but reports that the voices started recently.

e) Panic attacks: No panic attacks reported.

f) PTSD: Patient denies flashbacks, recurrent dreams, or repetitive thoughts about her father,

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