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Psychiatric  soap note

Chief Complaint: “Her mood has been good, she sleeps and eats well”

History of Present Illness

Patient is a 71-year-old female with GERD, hyperlipidemia, hypertension, unspecified depressive disorder, developmental delay with mild intellectual disability, generalized anxiety disorder, and memory loss currently managed on bupropion SR 150 mg p.o. B.i.d., donepezil 5 mg p.o. Q.a.m. And 10 mg p.o. Q.h.s., fluoxetine 20 mg p.o. Q.d., and memantine 10 mg p.o. B.i.d. The patient presented to the Clinic with caregiver for follow-up care and medication management.

Patient presents today with c/o of having difficulty with unsteady gait and hearing. The Staff was present during evaluation and corroborated the patient’s account. She’s currently being treated for UTI. They will follow up with her PCP. With regards to psychiatric symptoms, patient, and caregiver report that her mood has been good since her last visit, she sleeps and eats well. Denies SIHIAVH. She is tolerating her medications with no side effects.

  Past Medical History

Past Medical History reviewed at today’s visit

Family History

Family History reviewed at today’s visit.

Social History

Social History reviewed at today’s visit.

Allergies

Keflex TABS

Tuberculin PPD TEST

 Namenda

Review of Systems

The 10 point review of systems was completed and was negative other than as noted in the HPI

Physical Exam

General appearance: well-groomed and clean.

Behavior: cooperative. pleasant, joking

Mood: good.

Affect: full and bright.

Eye Contact: Normal.

Speech: regular rate/rhythm and normal volume.

Psychomotor: Normal.

Thought Processes: goal directed.

Thought Content: No paranoia or delusions expressed; the patient denied auditory and visual hallucinations; the patient did not appear to be responding to internal stimuli.

Associations: normal associations, homicidal ideation

Insight: good.

Judgement: good.

Concentration: intact.

Language: normal form and syntax.

Fund of knowledge: intact.

  Assessment

Patient presents with her caregiver, reports that her mood’s good, sleeps and eats well , denies SIHIAVH. Her affect seems congruent with her reported mood. currently on antibiotics for UTI, seems concerned about her unsteady gait and will follow up with her PCP. Patient is tolerating her current psychotropic dose, will not make any adjustment today . She will return to the clinic in 3 months.

Differential Diagnosis with rationale

Diagnosis

1. Depression (F32.A)

2. Generalized anxiety disorder (F41.1)

  Plan with rationale

1. Continue: Bupropion HCl ER (SR) 150 MG Oral Tablet Extended Release 12 Hour (Wellbutrin SR); TAKE 1 TABLET BY MOUTH TWICE DAILY

2. Continue: Fluoxetine HCl – 20 MG Oral Capsule; TAKE ONE CAPSULE BY MOUTH EVERY DAY

-Continue Prozac 20 mg daily for depression and anxiety

-continue bupropion 150 mg twice daily for depression and anxiety

-return to clinic in 3 months

Education

-Call the Suicide Hotline at 1-800-273-8255 in case of suicidal ideation. 

-Go to the emergency department or call 911 if you feel that you will harm yourself or someone else or are unable to keep yourself safe.

-Safety plan has been reviewed with patient. 

-call clinic with any questions

-follow up with PCP/other medical specialists for unsteady gait

Coding

98969