Focused Soap Note
Give the paper to 584…..
Kindly prepare the soap and you can add any of your information.
Chief Complaint: The patient is seen for initial medication assessment with complaint of “I was diagnosed with ADHD as a child, but never got treated and I am struggling at this time”
Biopsychosocial Assessment : Age, ethnicity, religion, marital status, etc.
The patient is a 33 years old African American Male , Single
History of Present Illness:
The patient reports he was always in trouble as a child and
growing up was not easy. The patient reports he has been struggling with depression since having twins.
The patient endorses depressive symptoms, including
sleep alteration, loss of interest in pleasurable activities,
feelings of guilt/worthlessness/hopelessness, problems
with energy, problems with concentration, appetite
disturbance. Patient denies suicidal and homicidal ideation.
The patient endorses symptoms of generalized anxiety,
including excessive worrying throughout the day,
associated with, restlessness, easy fatigability, difficulty
concentration, irritability, muscle tension and disrupted
sleep.
The patient endorses symptoms of inattentiveness
including having a short attention span and being easily
distracted, making mistakes, in work or at school,
appearing forgetful or losing things, being unable to stick
to tasks that are tedious or time-consuming, appearing to
be unable to listen to or carry out instructions, constantly
changing activity or task, having difficulty organizing
tasks.
The patient endorses symptoms of hyperactivity and
impulsiveness including being unable to sit still, especially
in calm or quiet surroundings, constantly fidgeting, being
unable to concentrate on tasks, excessive physical
movement, excessive talking, being unable to wait their
turn, acting without thinking, interrupting conversations,
little or no sense of danger.
Psychiatric History
The patient reports prior diagnosis of ADHD
Trauma History : Type, person involved
The patient reports he struggle as a child and went through a lot of traumatic situations. The patient reports they moved from
Family Psychiatric History
Brother -Anxiety, depression, PTSD
Father – Drug dealer
Mother – Depression
Substance Use
YES / NO
Marijuana: NO
Alcohol: NO
Tobacco: NO
Caffeine: YES
Other: NO
Social History
The patient reports
Patient denied suicidal ideation:
The patient denied
Education/Vocational History
High School / Employed
Religious / Spiritual Involvement:
Religious / Spiritual Involvement: The patient denied
Risk Assessment
Suicidal Ideation
NO
Homicidal Ideation
NO
ROS
General Appearance: Appears Stated Age
HEENT: PERRLA, Normocephalic, Atramatic
Neck: Supple, FROM, and no masses or goiter on Thyroid
Cardiovascular: RRR
Respiratory: CTA, Equal Breath Sounds and Chest Expansion
Abdomen: Soft, Non-Tender, BS x 4
Neurologic: Cranial Nerves II – XII grossly intact and no focal neuro deficits
Extremities: Within Normal Limits
Spine: Within Normal Limits
Grooming and Appearance:
Grooming and Appearance: Neatly dressed, Well groomed
Eye Contact:
Eye Contact: Direct
Psychomotor Behavior:
Psychomotor Behavior: Fine Motor-WNL, Gross Motor-WNL
Speech:
Speech: Normal rate and volume
Language:
Language: Coherent
Cooperation:
Cooperation: Cooperative
Attitude:
Attitude: Appropriate
Cognition Attention Span and Concentration:
Attention Span and Concentration: Alert, Intact
Past Medical History:
Illness, Injuries, Operations, and Treatments: None
Orientation to Time, Place, and Person:
Orientation to Time, Place, and Person: Oriented X4
Recent Memory:
Recent Memory: Intact
Remote Memory:
Remote Memory: Intact
Fund of Knowledge:
Fund of Knowledge: WNL
Emotional State Mood:
Mood: Happy
Affect:
Affect: Alert
Appropriateness:
Appropriateness: Appropriate to the situation
Judgment and Insight Judgment:
Judgement: WNL
Insight:
Insight: WNL
Thought Processes Rate:
Rate: Normal Rate and Rhythm
Abstract Reasoning:
Abstract Reasoning: Intact
Associations:
Associations: Intact
Computation:
Computation: Able to complete complex computation
Content:
Content: Clear, Logical
Abnormal or Psychotic Thoughts:
Abnormal or Psychotic Thoughts: None
Past Medical History
Current Symptoms and Problems: No Known Allergies
Current Medications:
Current Medications: No current medications on file
Past Medication and Side Effects:
Medication Reactions and Side Effects: None
Diagnosis:
Treatment Plan: Start Zoloft 50mg daily for anxiety and depression. Follow up in a month.
Medication Management
Current Medications: -Drug Name: sertraline, Strength: 50 mg, Directions: Take half a tablet by mouth daily for two week and then take one tablet by mouth daily after. Form: tablet.
-Drug Name: atomoxetine, Strength: 18 mg, Directions: Take one tablet by mouth daily in the morning. Form: capsule.
Clinical Assessment and Treatment Plan:
Clinical Assessment and Treatment Plan: The patient current symptoms is consistent with anxiety and ADHD. The patient seem to be going through life changes making it hard for him to control his ADHD and anxiety symptoms which he has been doing well in the past.
90792 – Psychiatric diagnostic evaluation with medical services:
90785 – Interactive Complexity is an add-on code:
96127-Behavioral Assessment:
Patient/Medication Education
Patient/Change Medical Plan
Reasons for Modifications or Continuation of Current Medications in Plan: • Patient educated about symptoms, illness, and diagnosis. Treatment options reviewed. Patient verbalized understanding and agreement with treatment plan/recommendations.
• Advised routine follow-up with PCP with lab testing. Discussed potential medical causes of current symptoms and importance for additional testing with PCP as needed.
• Discussed benefits, risks, and side effect profile of medication/s with the patient. They verbalized willingness to take the medication/s as prescribed. Counseled the patient on the importance of medication compliance and to not discontinue medications without medical advice as withdrawal symptoms and/ or worsening of symptoms may occur.
• Antidepressants: the patient was informed of possible adverse effects including, but not limited to weight gain, headaches, dizziness, nausea/vomiting, abdominal pain, diarrhea/constipation, tremors, muscle pain/aches. This includes black box warning of emergence of suicidal ideations. The patient expressed understanding. Alternatives to this medication were also discussed with the patient, including risks of not taking medications, and the patient was agreeable to the above choice.
• Antipsychotics: the patient was informed of possible adverse effects including, but not limited to akathisia, extrapyramidal symptoms, dystonia, drowsiness, and long-term concerns for tardive dyskinesia, weight gain, insulin resistance, dyslipidemia, and cognitive slowing. The patient expressed understanding.
Alternatives to this medication were also discussed with the patient, including risks of not taking medications, and the patient was agreeable to the above choice.
• Benzodiazepines: Discussed and educated the patient that benzodiazepines are generally not intended for prolonged use. They are likely to cause tolerance and dependence over time, and can cause disinhibition, cognitive impairment, and increase risk of falls. They are not recommended to be used concurrently with narcotics, hypnotics, and/or other benzodiazepines, as they also increase the risk of profound sedation, respiratory depression, coma, and even death. They are also not to be used with any alcohol for the same reasons. A plan to taper benzodiazepines over time was also discussed, along with options for alternative anxiolytics intended to be suitable replacements.
• Stimulants: May cause increase blood pressure and heart rate, may cause psychotropic or manic symptoms in patient with no prior history or increase in patient with preexisting psychiatric illness. have been associated with weight loss and slowing of growth rate in children (Monitor Height and weight accordingly). May result in peripheral vasculopathy and Raynaud is phenomenon. May cause increase agitation, anxiety, headache, insomnia, loss of appetite and nervousness.
• Patient advised to avoid driving or operating heavy machinery until the patient is aware of how
medication affects him/her and feels can perform those functions safely.
• The patient was encouraged to spend time with family and friends who the patient is comfortable spending time with. Pt educated on the value of regular exercise in regulating mood and the importance of eating a healthy and balanced nutrition to enhance well-being.
• Patient advised against using alcohol and/or illicit substances while on psychotropic medication due to risk of negative interactions and is aware doing so will be at his/her own risk.
• Patient advised to call 9-1-1 or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal or homicidal ideation or plans.
Patient Understands and Agrees with Treatment Plan
Patient Understands They May Call at Any Time Prior to the Next Appointment
