Download Paul Cho Psych Soap Note (R2 Emergency Medicine) S: CC

Paul Cho
Psych Soap Note
(R2 Emergency Medicine)
S:
CC: Patient has suicidal ideations
HPI: 41 year old Caucasian male presents to Bradford Hospital ED via ambulance complaining of
depression and experiencing suicidal ideations. He has been admitted here in the past for a similar
problem. Patient states that he is sleeping less and less these days. His appetite has declined and he
feels very anxious often when he is alone. He is experiencing auditory hallucinations which began a few
hours ago when he began drinking at a local bar. Patient states that he drank “a lot” of beer and has
begun to hear voices encouraging suicide by cutting his wrists. The auditory hallucinations have become
worse just prior to arrival. There is no evidence suggesting that he has cut his wrists but there are scars
showing prior cutting. The patient has experience similar episodes in the past, multiple times, each time
involving alcohol. He states that he became depressed two years ago when he broke up with his
girlfriend. Patient denies dizziness, headaches, shortness of breath, chest pain, palpitations and
abdominal pain.
ROS:
General: No complaint of fever or chills. Patient does not complain of any significant changes in weight
or temperature intolerances
Head: See above
Eyes: Denies eye pain, discharge or acute vision changes
ENT: Denies tinnitus, ear pain, changes or loss of hearing, sinus congestion, sore throat or difficulty
swallowing
Neck: Denies pain, injury or swelling
Cardiovascular: Denies chest pain or palpitations
Pulmonary: Denies cough, wheezing, shortness of breath, sputum production, dyspnea on exertion and
paroxysmal nocturnal dyspnea
Abdomen: Denies abdominal pain, nausea, vomiting, diarrhea, constipation
Neuro: Denies headaches, weakness, numbness, tingling and seizures
Musculoskeletal: Pain in left wrist and dorsal aspect of right forearm.
Psych: Positive for anxiety, depression, auditory hallucinations and suicidal ideations
Allergies: No known drug allergies
Medications:
Fluoxetine Oral 20 mg daily
Carafate Oral 1 gram twice a day
Vistaril Oral 25 mg as needed, four times a day
Zocor Oral 20 mg daily
Campral Oral 666mg three times a day
Coumadin Oral 7.5 mg daily
Past Medical History:
The patient states that he has a history of mental health issues and has suffered a pulmonary emboli “a
few years ago”. He claims to be depressed, have ulcers in his stomach and have high cholesterol. He
states that he also on medication for alcohol dependence.
Immunizations:
Last tetanus immunization was greater than 10 years ago and Flu vaccine is not up to date.
Surgical History;
Appendectomy in 2008
Family History:
Patient refuses to speak of his family but does deny depression in immediate family members.
Social History:
Patient chews tobacco (1 can/3 days) and uses alcohol on a daily basis. On the weekdays he drinks a 4-5
beers and on the weekends he drinks 12-16 beers. Patient denies use of any illegal substances. He is
currently unemployed and lives alone.
O:
General: Alert, without acute distress, afebrile, poor hygiene, appears to be his stated age of 41
Vitals: BP 107/80 Pulse 104 Resp 18 Temp 96.6 Pulse Ox 96% on R/A Wt 95.25kg Height
6’4’’
Head: Atraumatic,normocephalic. no tenderness or obvious abnormalities present
Eyes: PERRLA, conjunctive pink and moist, nonicteric, EOM’s intact, negative for nystagmus
Fundoscopic: Disc with clear border bilaterally, cup:disc is 1:3, no AV nicking, cotton wool patches,
papilledema or hemorrhages noted
Ears: No external ear deformities or tenderness noted. External canal is pink with minimal cerumen and
no discharge present. TM visualized bilaterally with pars tensa being pearly gray with light reflex
at 4:00 position. No erythema or perforations noted bilaterally.
Nose: No deformities noted. Nasal mucosa is coral pink, moist and without drainage. No obstruction
noted.
Mouth: Lips symmetrical without any lesions or cheilosis present. Oral mucosa pink without lesions or
erythema. Dentition is poor with mildly receding gums. Wharton’s and stenson’s ducts were
visualized without obstruction. Tongue is free of lesions and abnormal papillae and midline
along with the uvula upon phonation. Palpation under the tongue, around the gums and cheeks
reveal no masses or tenderness.
Neck: No JVD or bruits. Trachea midline without visible masses. Thyroid palpable without enlargement
and no masses noted. SCM and trapezius show full range of motion and strength of 5+.
Cardiac: Without lifts of heaves. PMI not visible but palpable at fifth intercostals space anterior axillary
line. Sinus tachycardia at 104 BPM. S1 and S2 noted, no murmurs, rubs, S3 or S4 noted.
Pulmonary: Symmetrical A/P-lateral ratio 1:2. No deformities, rashes, lesions or accessory muscle use
noted. No crepitus or tenderness noted upon palpation. Respiratory excursion full. Tactile
fremitus symmetrical in all areas. Percussion resonant throughout. Diaphragmatic excursion 3
cm bilaterally. Lung sounds clear to auscultation bilaterally in all lobes. Negative egophony,
bronchophony and whispered pectriloquy.
Abdomen: Abdomen without visible masses, lesions, rashes or erythema. Positive scar at lower right
quadrant from appendectomy noted. Active bowel sounds present in all four quadrants. No
abdominal/femoral bruits noted. Percussion reveals tympany in all quadrants. Liver percussed
out to 7 cm at right mid clavicular line. Spleen not percussible. Nontender upon light palpation
and deeper palpations reveals no splenomegaly or tenderness in the abdomen. Kidneys unable
to be trapped/palpated. No rebound tenderness present.
Neuro: Alert and oriented to time and place. Speech is without abnormalities. Able to read, spell
“WORLD” backwards and carry out simple commands. Short and long term memory tested by
asking about recent news reveals no deficiencies. No focal degenerative deficit appreciated.
MSE: His behavior is appropriate and he is fairly responsive to most of our questions. He has good eye
contact and his speech shows no deficit. His mood is neutral (though he claims to be depressed)
and his affect is neutral as well. He claims to have auditory hallucinations and suicidal ideations.
Musculoskeletal: Full range of motion in all joints without tenderness or crepitus
Labs: TSH, EKG and CMP all showed normal. CBC showed a low hematocrit value of 38.6. UA showed
ketone trace. Urine drug screen showed normal.
A:
Axis I: depression, suicidal ideation
Axis II: n/a
Axis III GERD
Axis IV: Broke up with girlfriend 2 years ago
Axis V: GAF 68
P:
1.
2.
3.
4.
Preliminary diagnosis of suicidal ideations and depression.
Continue current medications
Admit to Laroch, Roger.
Bed requested for Psych on 5th floor of hospital
Paul Cho PA-S