Comprehensive Psychiatric Soap Note Nursing Essay Example

Comprehensive Psychiatric Soap Note Nursing Essay Example


CC (chief complaint): Troubled sleeping

HPI: W. G. is a 43-year-old African-American male presenting with troubled sleeping. The patient reports being restless, with consistent headaches, sleep problems, and challenges controlling worries. The efficacy of Sertraline prescriptions he has been taking has reduced consistently over the past week.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

Comprehensive Psychiatric Soap Note Nursing Essay Example

Substance Current Use: The patient is an alcohol addict for the past 2 years. He experienced withdrawal complications 6 months ago and relapsed after abstaining from alcohol for consecutive four months.

Medical History: the patient has been taking 50mg of Sertraline daily for the past 6 weeks to relieve generalized anxiety disorder (GAD). He is also using 50mg/day naltrexone to relieve alcohol craving problems.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

  • Current Medications: 50mg of Sertraline per day and 50mg/day naltrexone.
  • Allergies: He is allergic to milk, pollen, and fur.
  • Reproductive Hx: He is sexually active and engages in oral and anal sex.
  • GENERAL: the patient has constant worries, fatigue, troubled sleeping, and unending headaches. He also reports increased craving for alcohol, spending much of his time drinking.
  • HEENT: Eyes: no visual loss, yellow sclerae. Ears: No hearing loss. Nose: runny nose. Throat: has sore throat.
  • SKIN: denies itching.(Comprehensive Psychiatric Soap Note Nursing Essay Example)
  • CARDIOVASCULAR: denies chest pain or pressure.
  • RESPIRATORY: denies shortness of breath
  • GASTROINTESTINAL: He experiences nausea and vomiting, especially after consuming cold food. Denies abdominal pain.
  • GENITOURINARY: Releases dark brown urine. Denies burning sensation when urinating,
  • NEUROLOGICAL: reports headache and dizziness. Denies paralysis and numbness.
  • MUSCULOSKELETAL: denies backpain, joint pain, or muscle pain.
  • HEMATOLOGIC: Denies bleeding, anemia, or bruising.(Comprehensive Psychiatric Soap Note Nursing Essay Example)
  • LYMPHATICS: no enlarged nodes or history of splectomy.
  • ENDOCRINOLOGIC: denies sweating, cold/heat intolerance, polyuria and polydipsia.


Diagnostic results:

Heart rate is 115 bpm

Temperature is 98.6°F

Positive alcohol urine test

C.B.C and C.M.P are within normal ranges.


Mental Status Examination

The patient is well-groomed and clean, with normal speech and tone. He is time-oriented and complies fully with the assessment process. He also depicts an intact thought process and intellectual functioning based on his fluency and accurate articulation of responses. However, he does not concentrate when a topic is discussed for an extended duration, and he seems restless, peeping through the window and persisting in being told when the session will end. He also seems uncomfortable talking about the alcohol problem. He also reports hallucinations and sometimes fears being alone at home. His recent memory is also clear, with frequent suicidal ideations, especially when the headaches and irritability are persistent and chronic. The patient also keeps apologizing for bothering other people with his drinking problem. He reports fearing public places; even attending his son’s parents’ day at the school is problematic due to the high potential of being misjudged.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

Diagnostic Impression

Generalized anxiety disorder (GAD): The patient depicts symptoms of generalized anxiety disorder. The patient reported having trouble sleeping, nausea, dizziness, and challenges controlling worries. During the assessment, the patient also depicted restlessness and irritability and reported occasional fatigue. These symptoms confirm the presence of GAD, as illustrated by DeMartini et al. (2019). DeMartini et al. (2019) argue that individuals with GAD exhibit pervasive anxiety and are at increased risk of suicide. The disorder is associated with persistent anxiety and worrying, significantly interfering with a person’s daily living. Therefore, the patient suffers from GAD since the identified symptoms fit the symptoms prevalent among patients with GAD.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

Social anxiety disorder: Social anxiety disorder is a mental health problem associated with an increased and intense fear of being misjudged or despised by other people (Koyuncu et al., 2019). It hinders individuals from socializing or engaging in interactions that could increase the potential of being misjudged. Such patients recognize the intensity of their fear and are keen to seek early treatment for the problem. In this case, the patient could also be experiencing social anxiety disorder due to his fear of public places and even failed to attend the son’s parents’ day at school. The patient is self-conscious and experiences stomachaches. His heart rate is also 115 bpm above the normal 60-100 bpm, indicating potential problems with fear.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

Alcohol Use Disorder (AUD): AUD refers to alcohol consumption patterns resulting in challenges controlling drinking and increased preoccupation with alcohol, irrespective of its associated problems. Castillo-Carniglia et al. (2019) observe that unhealthy alcohol consumption increases health and safety risks and even death. The disorder is associated with mental health problems like increased aggression and can co-occur with disorders like GAD. In this case, the patient exhibited unhealthy patterns of alcohol consumption and persistent craving for alcohol. He also experienced alcohol withdrawal symptoms, such as nausea. Thus, based on the symptoms, it can be concluded that the patient suffered from AUD. (Comprehensive Psychiatric Soap Note Nursing Essay Example)

Therefore, the primary diagnosis for the patient is GAD since most of the symptoms presented by the patient align with the DSM-5 diagnostic criteria for GAD. The criteria for GAD indicate that GAD patients exhibit anxiety and worry for more than six months. The patients also experience challenges controlling their worries (Park & Kim, 2020). Also, the anxiety and worries must be accompanied by at least three symptoms: restlessness, irritability, trouble sleeping, fatigue, and difficulty concentrating on activities (Park & Kim, 2020). The patient in the case study met all the DSM-5 diagnostic criteria requirements, hence the choice of Gad as the primary diagnosis.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

Treatment plan

The treatment plan for the patient should include cognitive behavioral therapy (CBT) and medications. Borza (2022) observes that CBT constitutes interventions emphasizing behavior change. CBT centralizes the assumption that beliefs cause people to think negatively, which later triggers anger and anxiety, leading to GAB. In this case, CBT will focus on developing skills like attention training and cognitive restructuring that can help challenge fearful behaviors and beliefs (Borza, 2022). Besides, the patient should also be subjected to FDA-approved pharmacological medications like Escitalopram (Lexapro) and paroxetine (Paxil) and off-label drugs like Serotonin (DeGeorge et al., 2022). These medications are classified as selective serotonin reuptake inhibitors (SSRIs), crucial in improving anxiety and depression symptoms. They increase serotonin levels in the brain, enhancing mood and sleep regulations.

Notably, the follow-up plan for the patient involved an initial visit within two weeks to assess the patient’s progress with the treatment process. Subsequent visits were conducted after every four weeks, during which the patient’s response to the treatment progress was assessed. The dosages for naltrexone were also increased from 50mg-100mg per day during the fourth visit, three months into the treatment process. It would be necessary to refer the patient to a CBT therapist to enhance his anxiety coping skills (Borza, 2022). These follow-up plans are essential in enhancing the patient’s coping strategies and adherence with the treatment process.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

Social determinant of health

Exercise is a healthcare promotion activity that should be considered for the patient with GAD. Saeed et al. (2019) observe that exercise reduces anxiety by diverting the patient’s mind from anxiety triggers like fear. Body movement also reduces muscle tension by lowering the body’s energy diverted into anxious feelings. Exercise intervention reduces disparities in mental care since it is easily accessible and can be performed by everyone. Consequently, patient education for GAD management should focus on the consumption of better nutrition and a balanced diet. According to Norwitz and Naidoo (2021), balanced nutrition helps in regulating anxiety disorders by influencing microbiome inflammation. Foods rich in omega 3-fatty acids, vitamin D, and ketogenic acids can effectively reduce anxiety, leading to positive health outcomes. Awareness about balanced diets can help GAD patients identify food sources with the required nutrient content, leading to positive health outcomes. Individuals who cannot access better food choices due to financial constraints can be educated on the selection of available food choices that still provide the required nutrient content. (Comprehensive Psychiatric Soap Note Nursing Essay Example)

Comprehensive Psychiatric Soap Note Nursing Essay Example


I would extensively explore the issue of alcoholism if I had the opportunity to assess the patient again. The patient’s GAD seemed to be exacerbated by the alcohol problem. Hence a thorough assessment of the issue is necessary for improved care. I followed up on the patient’s treatment progress up to the third month. He was showing a positive response to the GAD treatment interventions. However, alcohol remained a critical problem for the patient due to intense cravings. As a result, I would recommend enrolment into a rehabilitation center to help deal with the alcohol problem.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

Case Formulation and Treatment Plan:


I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.


Preceptor signature: ________________________________________________________


Date: ________________________




Borza, L. (2022). Cognitive-behavioral therapy for generalized anxiety. Dialogues in clinical neuroscience(Comprehensive Psychiatric Soap Note Nursing Essay Example).

Castillo-Carniglia, A., Keyes, K. M., Hasin, D. S., & Cerdá, M. (2019). Psychiatric comorbidities in alcohol use disorder. The Lancet Psychiatry6(12), 1068-1080.

DeGeorge, K. C., Grover, M., & Streeter, G. S. (2022). Generalized Anxiety Disorder and Panic Disorder in Adults. American Family Physician106(2), 157–164(Comprehensive Psychiatric Soap Note Nursing Essay Example).

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine170(7), ITC49-ITC64.

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in context8.(Comprehensive Psychiatric Soap Note Nursing Essay Example)

Norwitz, N. G., & Naidoo, U. (2021). Nutrition as a metabolic treatment for anxiety. Frontiers in psychiatry, 105(Comprehensive Psychiatric Soap Note Nursing Essay Example).

Park, S. C., & Kim, Y. K. (2020). Anxiety disorders in the DSM-5: changes, controversies, and future directions. Anxiety Disorders: Rethinking and Understanding Recent Discoveries, 187-196(Comprehensive Psychiatric Soap Note Nursing Essay Example).

Saeed, S. A., Cunningham, K., & Bloch, R. M. (2019). Depression and anxiety disorders: benefits of exercise, yoga, and meditation. American family physician99(10), 620–627(Comprehensive Psychiatric Soap Note Nursing Essay Example).

Comprehensive Psychiatric Soap Note Nursing Essay Example


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