PSYCH SOAP
Patient:
Address:
Date:
Provider:
M.C.
318 Tompkins St., Olean, NY
1/23/2013 11:00 AM Office Visit
Jim Tkacik, PA-C; Candy Hull, PA-S
DOB: 12/11/1961
Dept:
Family Practice
CC: “Having uncontrollable mood swings for the past week.”
HPI:
51 y/o males presents to clinic with 2 year hx of bipolar II disorder with depression and anxiety. He reports for the last
week his mood has been either severely depressed or overly manic with no periods of stability. He reports problems with
concentration, focus, anxiety, motivation, and inability to control his mood swings. He has been reluctant to use
antipsychotic medications in the past, and discontinues use of Risperdal and Wellbutrin when he feels he is “stable”. He
denies any pain, SI/HI, or any triggers for his mood instability this past week. He denies alcohol or drug abuse. He does
smoke 1 pack of cigarettes a day. He has not taken any medications for his mental instability this past week and reports it
has not gotten any worse or better, this is why he came in today. He denies any seizures, syncope, SOB, nightmares,
hallucinations, flashbacks, anger, hostility, irrational thoughts, speech disorders, memory changes, fatigue, insomnia.
No other medical concerns voiced today.
Meds:
1. Metoprolol Tartrate 50mg tablet qd PO
2. Furosemide 40mg tablet qd PO
3. Aspirin 81mg tablet qd PO
Allergies: NKDA
PMH:
Child: None
Surgical Hx: None
Hospitalization: None
Injuries: None
Immunizations: MMR and dTap as a child. Does not get influenza, tetanus, or pneumovax.
Comorbidities: HTN
FH:
Mother: alive, has breast cancer. No hx HTN/heart disease, hyperlipidemia, stroke, DM, chronic respiratory disease
Father: alive, has bipolar disorder, HTN and hypercholesteremia. No hx of cancer, stroke, DM, chronic respiratory disease
MGM: deceased from AMI. No hx of cancer, hyperlipidemia, stroke, DM, chronic respiratory disease
MGF: deceased from unknown cause. No known cancer, HTN/heart disease, hyperlipidemia, stroke, DM, chronic
respiratory failure
PGM: deceased from respiratory failure, had COPD. No hx of HTN/heart disease, hyperlipidemia, cancer, stroke, DM
PGF: deceased from heart failure. No hx of DM, hyperlipidemia, cancer, stroke, chronic respiratory failure
SH:
Born and raised in Olean, NY. No recent travel. Does not work. Lives with girlfriend. Has two grown male children that
live in area, has minimal contact with them. Does smoke, denies smokeless tobacco use. Is sexually active. Does not
exercise.
ROS:
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General: Reports decreased appetite, weight loss. Denies any chills/fevers
Skin: Denies any skin rashes, lesions, dryness, pruritus, or ecchymosis
Head: Denies any syncope, lightheadedness, headaches
Eyes: Denies any change in visual acuity, blurred vision, diplopia, or dry eyes
5. Ears, Nose, Sinuses: Denies any ear pain, change in hearing, tinnitus, epistaxis, runny nose, sinus tenderness,
swollen glands
6. Throat: Denies any facial pain, mouth ulcerations/sores, dental pain or sensitivity, sore throat, difficulty
swallowing
7. CV: Denies any chest pain, DOE, palpitations, lightheadedness, dizziness
8. Respiratory: Denies any SOB, cough, hemoptysis, pleuritic chest pain
9. GI: Denies abdominal pain, nausea, vomiting, heartburn, constipation/diarrhea, rectal pain, bleeding, melena
10. Vascular: Denies any ulcerations or color changes noted
11. Musculoskeletal: Denies any back pain, muscle aches, joint stiffness, cramping, edema
12. Hematologic: Denies any bleeding, bruising
13. Endocrine: Denies any polydipsia, polyuria, polyphagia, heat/cold intolerance, diaphoresis
14. Psychiatric: See HPI
PE:
BP 128/74, HR 78, T 98.6 °F, RR 18, Ht 72”, Wt 265#, O2 98% @ room air, Pain 0/10
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General Appearance: WDWN WM in NAD, appearing stated age. Depressed affect
Skin: No rashes or lesions noted. Bronze color, warm, moist with good turgor. Capillary refill <2 seconds b/l.
Skull/scalp: Equal b/l hair distribution without nits. No boney abnormalities or tenderness palpable.
HEENT: Full visual fields b/l in all 4 quadrants, bulbar and sclera clear, PERRLA, EOMI without nystagmus/lid
lag/strabismus or discharge. Retina deep orange, disc yellow, no exudates or hemorrhages visualized b/l. Hearing
equal b/l with scratch test, TM’s visualized b/l, pars tensa pearly gray, external canal fleshy pink without
discharge or cerumen, erythema, fluid levels, scar tissue, perforations, or drainage. Nasal musosa pink and
turbinates visualized without drainage, edema, or obstruction. Moist mucosa/gums without oral or pharyngeal
masses, ulceration or thrush. No sinus tenderness.
Neck: Trachea midline, supple, smooth carotid upstrokes without JVD, no palpable thyromegaly or LAD. Full
ROM without crepitus or tenderness.
CV: RRR, S1 > S2 heard without any appreciable murmurs, rubs, gallops. PMI visible at L fifth intercostal space
at anterior axillary line. Palpation without tenderness, lifts, heaves or thrills. PMI palpable at L 5th ICS at AAL.
Respiratory: Symmetrical A/P-Lateral ratio 1:2. No rashes, deformities, intercostal retractions, or accessory
muscle use noted. Palpation without tenderness or masses noted. Respiratory excursion full. Tactile fremitus
symmetrical throughout all areas. Percussion resonant throughout thorax. CTA b/l.
GI: abdomen is protuberant, without deformity, no abdominal/femoral bruits noted. No AAA appreciated. Active
bowel sounds present all 4 quadrants, no appreciable hepatosplenomegaly, no palpable masses. Periumbilical and
LUQ tympanic upon percussion. Liver percussible at 6cm right MCL. Spleen, bladder not percussible. Abdomen
soft, nontender. Light & deep palpation reveal no masses or tenderness. No rebound tenderness or guarding.
Musculoskeletal: No pain on palpation over bony prominence, no edema, no evidence of gout, no joint or bony
deformity, no crepitus. Full passive and active ROM.
Extremities: no clubbing or cyanosis
Neurologic: A&O x3. Speech intact without aphasia. Short and long term memory without deficiencies. Without
fasciculations or other involuntary movements. Strength equal b/l, sensation equal b/l in extremities and torso.
Gait without ataxia, negative pronator drift, negative Romberg.
MSE:
Appearance – pt. is well groomed, showered, and appropriately dressed
Behavior – appropriate with no abnormal movements. Good eye contact
Attitude - cooperative
Speech – good communication skills without vocabulary problems, stutter, or loudness
Psychomotor – no tremor, ataxia, or retardation
Cognition - appears intact, understanding conversation and psychiatric situation clearly
Insight – good understanding of current condition and change in mood
Judgment - sought help recognizing mood instability and increased depression
Impulse control – not impulsive at this time, maintaining control
Sensorium – spelled WORLD backwards appropriately
ASSESSMENT/PLAN:
1. Axis I: Bipolar I disorder
a. Start Risperdal 0.5mg tablet bid PO
b. Discussed SE: orthostatic hypotension, tachycardia, sedation, dystonia, sexual dysfunction, constipation
c. Discussed medication compliance
2. Axis I: Other personality disorder
a. Start Diazepam 5mg tablet bid PO
b. Discussed SE: sedation, hypotension, bradycardia, rash
c. Discussed medication compliance
3. Axis I: Major depressive disorder
a. Start Wellbutrin XL tablet 150mg PO
b. Discussed SE: seizure, agitation, insomnia, headache, tachycardia
c. Discussed medication compliance
4. Referral to psychology
a. Discussed ongoing counseling
b. Discussed family and social support system
5. Preventative health office visit
a. Referral for labwork: CBC, CMP, TSH, UA, lipid profile
b. Discussed healthy diet and regular exercise
c. Discussed mental health illness
d. Provided educational pamphlets on bipolar I disorder
e. Provided educational pamphlets on coping mechanisms and stress reduction
6. RTC 1 month or sooner if needed
7. Go to ED if symptoms worsen or any adverse drug reaction to medications
8. Patient verbalized understanding
Candy Hull
Candy Hull, PA-S
1/23/13, 11:35 a.m.