Use the Initial Psychiatric Assessment SOAP Note template to complete the documentation with the information provided, diagnose the patient and design a treatment plan.
Your writing Assignment should: follow the conventions of Standard English (correct grammar, punctuation, etc.); be well ordered, logical, and unified, as well as original and insightful; display superior content, organization, style, and mechanics; and; use APA formatting and citation style.
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.
Assessment
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 “feel on edge.” 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.
Treatment options
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.
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.
Vitals:
138/80
4
20
78
99%
5’10”
188 lbs.
Advice and recommendations
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.
