Psychiatric progress soap notes
Name: W.K Date: 01/18.23
TELEHEATH INFOR:
The Patient, a 29-year-old female office manager, presented to the telehealth intake with a history of depression, panic disorder, and anxiety. She reports that she has been having these conditions since childhood especially middle school. Pt reports that her situation begun worsening one months ago, with feelings of hopelessness. Patient has a history of ideational thoughts on harm, hx of wrist cutting at age 11 thinking it would take suffering away. She denies any pain and her history of allergies is unremarkable. Wisdom tooth removed, surgery on finger after care accident. C-section for daughter. She has a history of car accident; a rollover car accident 8 years ago and minor accidents. Patient has a psychiatric visit in the past due to postpartum depression and was assessed and discharged. Patient reports feeling anxious and depressed, with anxiety at a 5-6/10 and depression at a 4-5/10 depending on situation. Reports waking up with racing heart rate and anxiety can go up to 9/10. Patient reports triggers as a desire for everything to be perfect and getting angry when anxious. Patient denies thoughts of suicide or hallucinations/delusions and reports no current anxiety coping skills. Patient has ADHD and is unable to meditate. The patient family history is remarkable for ADHD, father, and mental illness, suffered by patient’s uncle on the maternal side. Her social history is unremarkable, though she has a 6-year-old daughter. She admits that she is dating and is in a serious relationship, 90% relationship is good but when anxious sometimes brings about problems. She works as an office manager, engages a lot with her daughter, and like writing in her leisure time. Her diet is appropriate for her age and balanced. Patient denies hallucination. Patient denies smoking or drinking alcohol.
Anxiety triggers patient state “everything”. No real coping skills, reports she doesn’t smoke or drink to distract from anxiety. Writes sometimes to decompose, walks at the beach sometimes. Father and mother both have anxiety. Not sure what brings about nightmares, occurs 2-3 times a week. drinks only cup of coffee a day. Poor energy level, poor diet, trouble concentration, never diagnosed with ADHD but thinks she has it. At times feels hopeless but currently.
Well groomed, oriented, and healthy for her age. Patient skin color is good. Patient is cooperative but anxious. She appears confident. Patient appears normal but reports an anxious mood. She maintains eye contact. Patient reports having nightmares six months ago with no identified triggers and difficulty sleeping, low energy, and trouble concentrating. Patient reports a healthy relationship, but she acknowledges that she is sometime affected. There was no sign of delusional thinking with the patient in all her communication and she appeared goal oriented. Severe pain, panic disorder, and anxiety. She has a history of these disorder since childhood (5 years old). Patient also has a history of ADHD, postpartum depression. Has 2 minor accidents; irregular menses and will be seeing GYN soon.
Mother side no hx of mental illness, uncle has some issues.
Father has undiagnosed anxiety, ADHD. Takes meds for BP, neuropathy none on mental health. Denies hx of suicide in family.
Medication: Patient is currently taking Effexor 250 mg orally daily and Buspirone 7.5 mg orally three times a day. 17-18 was on celexa got pregnant and was later switched to clonidine for a little bit which helped but was later started on venlafaxine 250 mg five years ago but does not help with anxiety and has since been taking that. Adderall when she was 17-18 years. Thinks she has more psych issues. Has been only diagnosed with anxiety.
Plan: Recommend and ordered neuropsychological testing for ADHD and borderline personality disorder. Follow-up in two weeks and instruct patient to call with any questions. Provide patient with ADHD online information. Encourage patient to see a gynecologist for irregular menses.
K.W is a 29 yr old female telehealth intake visit; CC “I have dealt with panic disorder, severe depression, and anxiety as a child. Patient felt hopelessness a month ago: Hx of cutting wrist when she was 11 years. Denies pain, NKA. Rollover car MVA (8years ago), few minor accidents, Psychiatric visit due to postpartum depression, was assessed and d/c.
Reports anxiety as child at age 9-10. Most felt sad 9/10 of the time. Wakes up racing heart rate, “nightmares” thinks she is more anxious than depressed. Anxious today 6/10, depression today 5/10 but other others can more.
Triggers: Everything likes to be perfect, gets angry when anxious. Likes things her way, fight at times. Denies thoughts of suicide or hallucinations/delusions.
No anxiety coping skills. (Educate on coping skills) has ADHD can’t meditate.
Father has anxiety, ADHD (undiagnosed)
Maternal uncle has mental illness on and off and some arrest by police.
Has a 6year old daughter (c-section) full custody
Currently dating. Weight 180, ht 5’11.
LMP 12/20/22-reports irregular menses (will see Gynecologist soon).
Patient is an Office manager at grocery story
Appears normal, Mood; anxious, sleep-nightmares 6 months ago-no triggers, sleeps on and off, low energy, trouble concentrations. Has healthy relationship (sometimes anxiety affects it), enjoys work, loves to write
EDUCATION.
Continue Effexor 225 mg PO daily, monitor s/sx of buspirone 7.5 mg Po TID
ADHD online information
PLAN
Neuropsychologic testing? ADHD, borderline personal) F/U in two weeks
Call with any questions