{"id":24389,"date":"2023-12-18T02:39:18","date_gmt":"2023-12-18T02:39:18","guid":{"rendered":"https:\/\/academicwritersbay.com\/writings\/allen-a-university-graduate-aged-21-years-attends-the-pharmacy\/"},"modified":"2023-12-18T02:39:18","modified_gmt":"2023-12-18T02:39:18","slug":"allen-a-university-graduate-aged-21-years-attends-the-pharmacy","status":"publish","type":"post","link":"https:\/\/academicwritersbay.com\/writings\/allen-a-university-graduate-aged-21-years-attends-the-pharmacy\/","title":{"rendered":"Allen, a university graduate aged 21 years, attends the pharmacy"},"content":{"rendered":"
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\u00a0<\/p>\n

Allen, a university graduate aged 21 years, attends the pharmacy of the campus counseling health center and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge. The pharmacist calls the provider on duty at the psychiatric clinic for the counseling health center and she arrives.<\/p>\n

Assessment<\/strong><\/p>\n

As the PMHNP on duty, you invite Allen into the consultation room and ask him about his symptoms. He states that he has started a new job and that the palpitations start when he is feeling anxious. His symptoms are occurring most days of the week and he says it makes him \u201cfeel on edge.\u201d He adds that he does not want to socialize with his co-workers. It is starting to affect his sleep and he does not know what to do. He also states that he has occasional pain in his chest.<\/p>\n

Treatment options<\/strong><\/p>\n

Allen is demonstrating symptoms of moderate anxiety, given his desire to avoid socializing, and has a degree of functional impairment. However, as he has potential cardiac symptoms, these issues could be related to another condition.<\/p>\n

When questioned, he confirms he has no other problems with his health, but you feel the patient needs further investigation. For example, tests to measure the electrical activity of his heart to rule out underlying cardiac problems should be considered. His presentation concerns you and you feel he needs these tests today to assess the differential diagnosis, as you are worried about his chest pain and palpitations.<\/p>\n

Vitals:<\/p>\n

    \n
  • 138\/80<\/li>\n
  • 4<\/li>\n
  • 20<\/li>\n
  • 78<\/li>\n
  • 99%<\/li>\n
  • 5\u201910\u201d<\/li>\n
  • 188 lbs.<\/li>\n<\/ul>\n

    Advice and recommendations<\/strong><\/p>\n

    You encourage Allen by saying that it is great that he felt he could talk to a pharmacist about this, but explain that he would benefit from continued management with you as the PMHNP and possibly some additional psychotherapy. You explain that his symptoms could be related to anxiety and that you think he may need something to help him manage. He agrees to let you continue the assessment and design a treatment plan.<\/p>\n

    \u00a0Use the Initial Psychiatric Assessment SOAP Note template\u00a0to complete the documentation with the information provided, diagnose the patient and design a treatment plan.\u00a0<\/p>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n

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    • \n
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      Initial_Psychiatric_SOAP_Note_Template_Adult_and_Child.docx<\/div>\n<\/p><\/div>\n<\/li>\n<\/ul><\/div>\n<\/p><\/div>\n

      Initial Psychiatric SOAP Note Template<\/b> <\/h1>\n<\/p>\n

      There are different ways in which to complete a Psychiatric SOAP (Subjective, Objective, Assessment, and Plan) Note. This is a template that is meant to guide you as you continue to develop your style of SOAP in the psychiatric practice setting. <\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n
      \n

      Criteria<\/b> <\/p>\n<\/td>\n

      		\n

      Clinical Notes<\/b> <\/p>\n<\/td>\n<\/tr>\n

      <\/td>\n <\/td>\n<\/tr>\n
      \n

      Informed Consent<\/b> <\/p>\n<\/td>\n

      		\n

      Informed consent given to patient about psychiatric interview process and psychiatric\/psychotherapy treatment. Verbal and Written consent obtained. Patient has the ability\/capacity to respond and appears to understand the risk, benefits, and <\/b>(Will review additional consent during treatment plan discussion) <\/p>\n<\/td>\n<\/tr>\n

      \n

      Subjective<\/b> <\/p>\n<\/td>\n

      		\n

      Verify Patient<\/p>\n

      Name:<\/p>\n

      DOB:<\/p>\n<\/p>\n

      Minor:<\/p>\n

      Accompanied by:<\/p>\n<\/p>\n

      Demographic:<\/p>\n<\/p>\n

      Gender Identifier Note:<\/p>\n<\/p>\n

      CC:<\/p>\n<\/p>\n

      HPI:<\/p>\n<\/p>\n

      Pertinent history in record and from patient: X<\/p>\n<\/p>\n

      During assessment: Patient describes their mood as X and indicated it has gotten worse in TIME.<\/p>\n<\/p>\n

      Patient self-esteem appears fair, no reported feelings of excessive guilt, <\/p>\n

      no reported anhedonia, does not report sleep disturbance, does not report change in appetite, does not report libido disturbances, does not report change in energy,<\/p>\n

      no reported changes in concentration or memory.<\/p>\n<\/p>\n

      Patient does not report increased activity, agitation, risk-taking behaviors, pressured speech, or euphoria. Patient does not report excessive fears, worries or panic attacks. <\/p>\n

      Patient does not report hallucinations, delusions, obsessions or compulsions. Patient\u2019s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.<\/p>\n<\/p>\n

      SI\/ HI\/ AV: Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate\/illegal behaviors.<\/p>\n<\/p>\n

      Allergies: NKDFA.<\/p>\n

      (medication & food)<\/p>\n<\/p>\n

      Past Medical Hx: <\/p>\n

      Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.<\/p>\n

      Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.<\/p>\n

      Surgical history no surgical history reported<\/p>\n<\/p>\n

      If Minor obtain Developmental Hx: (most often from parents), in utero, birth and delivery hx, early childhood, school hx, behavior, etc\u2026<\/p>\n<\/p>\n

      Nutritional status (this is an important component to gauge how well the mind and body are being nourished for full function. Ex: lack of iodine create thyroid issues, thyroid issues creates metabolism issues which affects function of cognition, mood, etc\u2026)<\/p>\n<\/p>\n

      Past Psychiatric Hx:<\/p>\n

      Previous psychiatric diagnoses<\/b>: none reported. <\/p>\n

      Describes stable course of illness. <\/p>\n

      Previous medication trials<\/b>: none reported. <\/p>\n<\/p>\n

      Safety concerns: <\/b> <\/p>\n

      History of Violence to Self:<\/u> none reported <\/p>\n

      History of Violence t o Others<\/u>: none reported <\/p>\n

      Auditory Hallucinations:<\/p>\n

      Visual Hallucinations:<\/p>\n<\/p>\n

      Mental health treatment history<\/b> discussed: <\/b> <\/p>\n

      History of outpatient treatment: not reported <\/p>\n

      Previous psychiatric hospitalizations: not reported <\/p>\n

      Prior substance abuse treatment: not reported <\/p>\n<\/p>\n

      Trauma history:<\/b> Client does not report history of trauma including abuse, domestic violence, witnessing disturbing events. <\/p>\n<\/p>\n

      Substance Use:<\/b> Client denies use or dependence on nicotine\/tobacco products. <\/p>\n

      Client does not report abuse of or dependence on ETOH, and other illicit drugs.<\/p>\n<\/p>\n

      Current Medications: No current medications.<\/p>\n

      (Contraceptives):<\/p>\n

      Supplements:<\/p>\n<\/p>\n

      Past Psych Med Trials:<\/p>\n<\/p>\n

      Family Medical Hx:<\/p>\n<\/p>\n

      Family Psychiatric Hx:<\/p>\n

      Substance use<\/p>\n

      Suicides<\/p>\n

      Psychiatric diagnoses\/hospitalization<\/p>\n

      Developmental diagnoses<\/p>\n<\/p>\n

      Social History:<\/p>\n

      Occupational History: currently unemployed. Denies previous occupational hx <\/p>\n

      Military service History: Denies previous military hx.<\/p>\n

      Education history: completed HS and vocational certificate <\/p>\n

      Developmental History: no significant details reported.<\/p>\n

      (Childhood History)<\/p>\n

      Legal History: no reported\/known legal issues, no reported\/known conservator or guardian. <\/p>\n

      Spiritual\/Cultural Considerations: none reported.<\/p>\n<\/p>\n

      ROS:<\/p>\n

      Constitutional: No report of fever or weight loss. <\/p>\n

      Eyes: No report of acute vision changes or eye pain. <\/p>\n

      ENT: No report of hearing changes or difficulty swallowing. <\/p>\n

      Cardiac: No report of chest pain, edema or orthopnea. <\/p>\n

      Respiratory: Denies dyspnea, cough or wheeze. <\/p>\n

      GI: No report of abdominal pain. <\/p>\n

      GU: No report of dysuria or hematuria. <\/p>\n

      Musculoskeletal: No report of joint pain or swelling. <\/p>\n

      Skin: No report of rash, lesion, abrasions. <\/p>\n

      Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. <\/p>\n

      Hematologic: No report of blood clots or easy bleeding. <\/p>\n

      Allergy: No report of hives or allergic reaction. <\/p>\n

      Reproductive: No report of significant issues. (females: GYN hx; abortions, miscarriages, pregnancies, hysterectomy, PCOS, etc\u2026)<\/p>\n<\/p>\n<\/td>\n<\/tr>\n

      \n

      Verify Patient: <\/i>Name, Assigned\u00a0 identification<\/b>\u00a0number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. <\/p>\n<\/p>\n

      Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. <\/i> <\/p>\n<\/p>\n

      HPI: <\/i> <\/p>\n<\/p>\n<\/p>\n

      , Past Medical and Psychiatric History,<\/i> <\/p>\n

      Current Medications, Previous Psych Med trials, <\/i> <\/p>\n

      Allergies.<\/i> <\/p>\n

      Social History, Family History.<\/i> <\/p>\n

      Review of Systems (ROS) \u2013 if ROS is negative, \u201cROS noncontributory,\u201d or \u201cROS negative with the exception of\u2026\u201d<\/i> <\/p>\n<\/td>\n

      		 <\/td>\n<\/tr>\n
      \n

      Objective <\/b> <\/p>\n<\/td>\n

      		\n

      Vital Signs: <\/b>Stable <\/p>\n<\/p>\n

      Temp:<\/p>\n

      BP:<\/p>\n

      HR:<\/p>\n

      R:<\/p>\n

      O2:<\/p>\n

      Pain:<\/p>\n

      Ht:<\/p>\n

      Wt:<\/p>\n

      BMI:<\/p>\n

      BMI Range:<\/p>\n<\/p>\n

      LABS:<\/p>\n

      Lab findings WNL<\/p>\n

      Tox screen: Negative<\/p>\n

      Alcohol: Negative<\/p>\n

      HCG: N\/A <\/p>\n<\/p>\n

      Physical Exam:<\/p>\n

      MSE:<\/p>\n

      Patient is cooperative and conversant, appears without acute distress, and fully oriented x 4. Patient is dressed appropriately for age and season. Psychomotor activity appears within normal.<\/p>\n

      Presents with appropriate eye contact, euthymic affect \u2013 full, even, congruent with reported mood of \u201cx\u201d. Speech: spontaneous, normal rate, appropriate volume\/tone with no problems expressing self. <\/p>\n

      TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed.<\/p>\n

      Cognition appears grossly intact with appropriate attention span & concentration and average fund of knowledge. <\/p>\n

      Judgment appears fair . Insight appears fair<\/p>\n<\/p>\n

      The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning.<\/p>\n<\/p>\n

      Diagnostic testing: <\/p>\n

      \u00b7 PHQ-9, psychiatric assessment<\/p>\n<\/p>\n<\/td>\n<\/tr>\n

      \n

      This is where the \u201cfacts\u201d are located. <\/i> <\/p>\n

      Vitals, <\/i> <\/p>\n

      **Physical Exam (if performed, will not be performed every visit in every setting)<\/i> <\/b> <\/p>\n

      Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results.<\/i> <\/p>\n<\/td>\n

      		 <\/td>\n<\/tr>\n
      \n

      Assessment<\/b> <\/p>\n<\/td>\n

      		\n

      DSM5 Diagnosis: with ICD-10 codes<\/p>\n<\/p>\n

      Dx: \u2013 <\/p>\n

      Dx: \u2013 <\/p>\n

      Dx: \u2013 <\/p>\n<\/p>\n<\/p>\n

      Patient has the ability\/capacity appears to respond to psychiatric medications\/psychotherapy and appears to understand the need for medications\/psychotherapy and is willing to maintain adherent. <\/p>\n

      Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.<\/p>\n<\/td>\n<\/tr>\n

      \n

      Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes<\/u>, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. <\/i> <\/p>\n<\/p>\n

      Informed Consent Ability<\/i> <\/p>\n<\/td>\n

      		 <\/td>\n<\/tr>\n
      \n

      Plan<\/b> <\/p>\n<\/td>\n

      		\n

      Inpatient:<\/p>\n

      Psychiatric. Admits to X as per HPI. <\/p>\n

      Estimated stay 3-5 days <\/p>\n<\/p>\n

      Patient is found to be stable and has control of behavior. Patient likely poses a minimal risk to self and a minimal risk to others at this time. <\/p>\n

      Patient denies abnormal perceptions and does not appear to be responding to internal stimuli.<\/p>\n<\/p>\n

      Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: <\/p>\n<\/p>\n

      \u00b7 No changes to current medication, as listed in chart, at this time <\/p>\n

      \u00b7 or\u2026Zoloft is an excellent option for many women who experience any menstrual cycle complaints. I usually start at 50 mg and move to 100 week 6-8. f\/u within 2 weeks initially then every 6-8 weeks. <\/p>\n

      \u00b7 Psychotherapy referral for CBT<\/p>\n

      Education, including health promotion, maintenance, and psychosocial needs<\/p>\n

      \u00b7 Importance of medication<\/p>\n

      \u00b7 Discussed current tobacco use. NRT not indicated. <\/p>\n

      \u00b7 Safety planning<\/p>\n

      \u00b7 Discuss worsening sx and when to contact office or report to ED<\/p>\n

      Referrals: endocrinologist for diabetes<\/p>\n

      Follow-up, including return to clinic (RTC) with time frame and reason and any labs that are needed for next visit 2 weeks<\/p>\n<\/p>\n

      \u2612 > 50% time spent counseling\/coordination of care.<\/p>\n<\/p>\n

      Time spent in Psychotherapy 18 minutes<\/p>\n<\/p>\n

      Visit lasted 55 minutes<\/p>\n<\/p>\n

      Billing Codes for visit: <\/p>\n

      XX<\/p>\n

      XX<\/p>\n

      XX<\/p>\n<\/p>\n

      ____________________________________________<\/p>\n

      NAME, TITLE<\/p>\n<\/p>\n

      Date: Click here to enter a date. Time: X<\/p>\n<\/p>\n<\/td>\n<\/tr>\n

      \n

      Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment and include patient education. <\/i> <\/p>\n<\/p>\n<\/td>\n

      		 <\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/p>\n

      NW_11\/1\/20<\/p>\n","protected":false},"excerpt":{"rendered":"

      \u00a0 Allen, a university graduate aged 21 years, attends the pharmacy of the campus counseling health center and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge. The pharmacist calls the provider on duty at … Read more<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-24389","post","type-post","status-publish","format-standard","hentry","category-essaywr"],"_links":{"self":[{"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/posts\/24389","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/comments?post=24389"}],"version-history":[{"count":0,"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/posts\/24389\/revisions"}],"wp:attachment":[{"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/media?parent=24389"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/categories?post=24389"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/academicwritersbay.com\/writings\/wp-json\/wp\/v2\/tags?post=24389"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}