NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Patient details: John Dark, 24 Years male, American.

Subjective:

CC (chief complaint): “I am concerned about the continuous feeling of my heart beating irregularly.”

HPI: J.D., a 24-year-old male from the United States, reports that his heart palpitations began around six months ago and have occurred most days of the week for the past two months. He says his symptoms started before his new job and have worsened. The palpitations are usually triggered by anxiety, and he experiences them, particularly in social situations. The patient admits to avoiding socialization at work due to his constant nervousness. He claims that his symptoms have recently begun interfering with his sleep and that he sometimes experiences chest pain.

Past Psychiatric History: J.D denies any previous psychiatric diagnosis

Medication Trial: none

Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Use History: J.D. categorically denies any use of substances or addiction to tobacco, nicotine, illegal drugs, or alcohol.

Family Psychiatric/substance Use History: There is no recorded familial background of psychiatric conditions, substance abuse issues, or past suicidal endeavors

Medical History

  • Current Medications: No current medications.
  • Allergies: no reported drug, food, or environmental allergy.
  • Reproductive Hx: report not being sexually active at the moment

ROS (review of symptoms):

GENERAL: The patient does not experience any weight loss, fever, overall body weakness, or fatigue. 

HEENT: 

  • Head: There are no reported headaches or head injuries. 

  • Eyes: The patient did not notice any vision changes. 

  • Ears: No hearing loss was observed or reported by the patient. 

  • Nose: There were no reports of a runny nose or congestion. 

  • Throat: The patient has no difficulties with swallowing. 

SKIN: No rash, itching sensation, discoloration, wounds, or cuts

CARDIOVASCULAR: Occasionally experiences chest discomfort accompanied by irregular heartbeats. No swelling, difficulty breathing while lying down, or sudden nighttime awakening due to breathing difficulties.

RESPIRATORY: No coughing, production of phlegm, or shortness of breath was reported. GASTROINTESTINAL: No episodes of vomiting or diarrhea and maintains a normal appetite. Absence of stomach pain and no presence of blood in stool.

GENITOURINARY: No painful urination was experienced. 

NEUROLOGICAL: Denies symptoms like lack of coordination/muscle control, weakness/extreme fatigue causing fainting spells, dizziness/loss of balance sensation/tinnitus (ringing ears), or limb tingling sensations. Normal bowel movements were observed without any changes noted. MUSCULOSKELETAL: Free from stiffness/discomfort in joints/bones and has not experienced fractures/back pain/muscular soreness.

HEMATOLOGIC: Does not exhibit bruising/bleeding tendencies

LYMPHATICS: No swollen lymph nodes were detected 

PSYCHIATRIC: No history/experience with depression/anxiety disorders 

ENDOCRINOLOGIC: no signs/symptoms associated with excessive sweating/cold/hot intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not sexually active.

ALLERGIES: no allergic reaction reported

Objective:

Diagnostic results:

Vital Signs: Temp: 98.4°F, BP: 128/82, HR: 77, R: 20, O2: 98%

Assessment:

Mental Status Examination:

J.D., a male of American nationality, is in his mid-twenties and presents himself as looking similar to his actual age. He exhibits signs of lacking confidence by frequently avoiding direct eye contact. J.D. expresses feelings of unease, particularly when engaging in social interactions, and this feeling has been progressively intensifying recently. Furthermore, this anxiety is beginning to disrupt his sleep patterns. The patient denies having any thoughts related to self-harm or causing harm to others, as well as not experiencing any auditory or visual hallucinations. No other deviations are observed during the assessment of mental condition.

Diagnostic Impression:

  1. Generalized Anxiety Disorder: The patient’s ongoing and relentless experience of heart palpitations, which are directly correlated to their overwhelming anxiety levels, not only affect them physically but manifest as an avoidant behavior towards social settings. Additionally, this disorder disrupts the quality and consistency of their sleep patterns, further exacerbating the challenging symptoms associated with GAD. Generalized anxiety disorder is marked by excessive and uncontrollable concern and nervousness regarding various tasks or situations for a prolonged duration, typically six months (Munir & Takov, 2020; National Institute of Mental Health, 2022). The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) (Sarmiento & Lau, 2020) is the diagnostic criteria for GAD. A patient must experience at least three symptoms of an anxiety disorder: agitation, nervousness, exhaustion, difficulty focusing, irritability, muscle tension, and disturbed sleep.

  2. Panic Disorder: Patients experiencing occasional chest pain and the progressive intensification of symptoms may indicate a panic disorder. This psychological condition is characterized by recurring episodes of intense fear or anxiety accompanied by physical manifestations such as palpitations, shortness of breath, sweating, and avoidance behavior. Panic disorder is marked by recurring, unforeseen panic attacks- sudden surges of intense fear or discomfort- peaking in minutes (Cackovic et al., 2020). One notable aspect of panic disorder is that these episodes transpire without indication. 

  3. Social Anxiety Disorder: The patient’s avoidance of socialization at work and intense nervousness in social situations align with the diagnostic criteria for social anxiety disorder, a debilitating psychiatric condition characterized by excessive fear and discomfort in various interpersonal interactions. This disorder can significantly impact an individual’s daily functioning, leading to significant distress and impairment in personal and professional settings. (Koyuncu et al., 2019) However, it should be noted that true arrhythmic causes must always be rigorously ruled out before attributing palpitations solely to psychiatric disorders. While there is limited research specifically evaluating the prevalence or profile of palpitations associated with social anxiety disorder in India or any other specific region, previous studies have highlighted possible triggers such as cardiac arrhythmias, drug overdoses, thyroid disorders (which can elicit notable cardiovascular effects), as well as general manifestations linked to increased levels of anxiety.

Reflections:

If allowed to redo the session with this patient, I would seek more specific information regarding how often they experience palpitations and anxiety and what triggers these symptoms. Furthermore, it would be prudent to conduct a physical examination to evaluate their cardiovascular well-being and investigate any relevant medical history. Additionally, it is crucial to assess for other mental health conditions that may contribute to their presenting complaints. Regarding future appointments, positive outcomes from interventions would indicate their effectiveness, while negative results would necessitate reevaluating the treatment plan. In cases where follow-up is not possible or feasible, I suggest self-help resources for mild symptoms or strongly recommend consulting a healthcare professional for severe or ongoing issues.

Case Formulation and Treatment Plan: 

Assessment: The patient’s initial symptoms of heart palpitations and accompanying feelings of anxiousness suggest a complex relationship between physiological and psychological factors. Cardiac arrhythmias may cause an irregular heartbeat, while anxiety could indicate anxiety or panic disorder. Diagnostic exams, including an electrocardiogram, Holter monitor, and blood tests, will aid in evaluating the patient’s cardiovascular well-being. Simultaneously, a thorough psychiatric evaluation will examine mental health contributors. By comprehending the root causes and their interactions, we can customize a treatment plan that includes medical interventions like cardiology referrals and psychotherapeutic methods to effectively address the patient’s palpitations and anxiety.

Treatment Plan:

Because his patient is deemed stable and in control of his conduct, he will be placed in an outpatient treatment program. The risk evaluation reveals that the patient poses no danger to himself or others.

Diagnostic Tests:

EKG: to assess heart function and detect arrhythmias.

Blood tests to assess electrolyte levels, thyroid function, and cardiac enzymes.

Medication: Escitalopram 10 mg PO qDay was initially prescribed to help ease the patient’s anxiety and nervousness (Newman et al., 2022).

Interventions in Therapy:

Psychoeducation: Inform the patient about the causes of palpitations, anxiety, and potential triggers.

Cognitive Behavioral therapy addresses anxiety and panic symptoms and aims to identify and modify harmful cognitive patterns. In this therapy, the patient will receive CBT incorporating cognitive restructuring to identify negative beliefs causing their symptoms. The goal is to reframe thinking patterns with positive thoughts to reduce anxiety levels. This type of therapy will be administered for 12 weeks.

J.D. was referred to a psychologist for ongoing treatment.

Education

  • During the education process, it was emphasized to the patient that engaging in the regular exercise alongside high-intensity intervention programs has significantly reduced symptoms associated with an anxiety disorder. Regular physical activity also enhances sleep hygiene habits and contributes to minimizing daily episodes of anxiety.
  • To assist him in settling in fast in his new surroundings, the patient was advised to reach out to his coworkers with whom he feels comfortable talking.
  • We then discussed the benefits of using relaxation techniques, such as meditation, to alleviate anxiety (Newman et al., 2022).
  • We also talked about journaling and content recording to help you keep track of each anxiety episode and its related triggers. Patients are also encouraged to keep track of effective tactics for alleviating anxiety.
  • Discuss the medication’s risks and advantages, including any potential adverse effects.
  • Advise against rapid drug withdrawal without talking with healthcare specialists.
  • Inform the patient about potential interactions between pharmaceuticals, over-the-counter medications, herbal supplements, alcohol, and illegal drugs.
  • Emphasize the impact of substance usage on mental and physical health and sleep quality.

Disposition:

Encourage the patient to continue receiving case management and counseling.

In the event of suicide or homicidal ideas, provide emergency contact numbers, including the local crisis line and emergency services.

Follow-Up:

The patient was asked to be seen at the facility in two weeks

 

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