Progress Notes SOAPE - emedsa [PDF]

Writing progress notes - SOAPE style SOAPE Subjective The story so far.... main problems, presumptive diagnosis, tests and treatments Current or persistent symptoms+ inactive recent problems Relevant past medical history

Objective Examination finding Recent test results

Assessment New problems / diagnosis identified Ongoing problems / issues / diagnosis

Plan Treatments Tests Consults required (include future thoughts and contingencies - 'what if' scenarios)

Education Advice to patients regarding treatment Advice to patient about disease Advice to patient about future issues and response Yet again a familar case 17 yo unemployed male living with his family. Several months of social withdrawal, unkemptness and poor hygiene. Heavy tobacco smoker and regular cannabis user. Previous experimentation with amphetamines and LSD. Experiences paranoid beliefs that he is under surveillance by bikie gangs, phone is tapped and that listening devices are in his house. Also experiences auditory hallucination of persecutory nature and more recently, command hallucinations to commit suicide. Examination revealed casually dressed male with evidence of poor self-care. He was orientated to time, place and person but appeared anxious, fearful and agitated. Conversation was often tangential and preoccupied by themes of being killed by bikie gangs. He demonstrated impairment in short term memory that may have been influenced by his thought disorder. He showed poor insight and judgment and was resistive to admission and treatment. The patient was detained to the locked ward of a mental health unit whereupon he became increasing agitated and paranoid and attempted to abscond. This required temporary physical restraint. Eventually spontaneously settles without chemical sedation. Commenced on risperidone and agitation settles overnight but paranoia persists. Later in the week, behaviour settles and patient is transferred to open ward. Patient begins complaining of muscle stiffness and pain, stiff gait and hand tremor which is temporarily relieved with benztropine but followed by blurred vision and dry mouth. Persistent stiffness results in medication changed to olanzapine responding with gait improvement a few days later. The patient continued with individual supportive counseling and family meetings were organised for education. SOAPE after the first week........ S Day 7 admissionActive Problems1) First presentation of acute psychotic disorder - ongoing paranoia - recent move from closed to open ward) 2) THC abuse +/- others? 3) Agitation - settling now with risperidone (no longer absconding risk) Now complaining of muscle stiffness and pain, stiff gait, hand tremor O evidence of tremor and hypertonia with Parkisonian-like gait, currently no fever A 1) muscle stiffness - ?EPS reaction to antipsychotic ??early neuroleptic malignant syndrome (but unlikely due to short duration of new medication) 2) Paranoid psychosis - ongoing but settling P commence benztropine and observe for response, if ongoing issues consider switching to olanzapine, observe for new changes in mental state, fever and do serums CK (to rule out NMS). Organise Social work/Psychologist input later this week re family meeting. E Patient encouraged to be involved with ward activities and report any change in condition.