Step 1: You will use the
to:
- Compose a written comprehensive psychiatric evaluation of a patient you have seen in the clinic.
- Upload your completed comprehensive psychiatric evaluation as a Word doc. Scanned PDFs will not be accepted.
- For the Comprehensive Evaluation Presentation Assignment: You will need to get it signed by your preceptor for the presentation (actual signature, not electronically typed).
Step 2: Each student will create a focused SOAP note video presentation in the next assignment. See for more details.
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan.
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S = |
Subjective data: Patients Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS) |
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O = |
Objective data: Medications; Allergies; Past medical history; Family psychiatric history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam, (Focused), and Mental Status Exam |
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A = |
Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes |
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P = |
Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow up |
Patient 14
Gender: Male
Age: 29
Ethnicity: Hispanic
Race: White
Insurance: Medicaid
Reason for Visit: Follow-up
Chief Complaint: I still feel empty and unstable.
HPI:
29-year-old male presents for follow-up for borderline personality disorder with ongoing emotional instability and fear of abandonment. Reports mood swings, impulsivity, and difficulty maintaining relationships. Denies SI but reports past self-harm behaviors without current intent. Symptoms worsen with interpersonal conflict.
Clinical Note:
Affect labile, intense emotional expression, cooperative but easily frustrated. Thought process coherent.
Social Problems Addressed:
Interpersonal Relationships, Emotional instability, Impulsivity
Immunizations:
Up-to-date
CPT Code: 99214
Principal Diagnosis:
F60.3 Borderline Personality Disorder
Differential Diagnoses:
- F31.81 Bipolar II Disorder
Supporting: mood swings present but lack discrete hypomanic episodes - F33.1 Major Depressive Disorder
Supporting: mood symptoms present but reactive to interpersonal stressors - F41.1 Generalized Anxiety Disorder
Supporting: anxiety present but emotional dysregulation primary
Vitals:
BP: 118/74 | HR: 82 | RR: 14 | Temp: 98.4F | Ht: 511 | Wt: 180 lb | BMI: 25.1
Allergies: NKA
Procedures:
MSI-BPD screening tool, MSE, risk assessment
Treatment Plan:
- Lamotrigine 25 mg PO daily, #30, 1 refill (mood stabilization)
- Education: rash risk, titration schedule
Non-Pharmacological:
Dialectical Behavior Therapy (DBT) gold standard for emotional regulation and impulsivity
Mindfulness training to improve distress tolerance
Follow-Up:
2 weeks monitor mood stability and safety
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