AH is a 30 year-old female with complaints of not being able to fall asleep

CC/PMI: AH is a 30 year-old female with complaints of not being able to fall asleep. She has a

history of Bipolar disorder and ADHD, both of which are well controlled at the present time.

SH: Drinks three cans of Coca Cola per day and smokes 1 pack of cigarettes per day.

Medications:

Aripiprazole (Abilify®) 10 mg at bedtime

Divalproex (Depakote®) ER 1000mg daily

Methylphenidate (Ritalin®) 20mg three times daily

Citalopram (Celexa®) 20mg at bedtime

Allergies: NKDA

Physical Examination:

GEN: slender female, tired-appearing

VS: BP 120/67, HR 85, RR 12, T 98, Wt 100lb, Ht 5’5”

HEENT: normal

COR: normal

CHEST: normal

ABD: normal

EXT: normal

NEURO: oriented to time, place and person; normal deep tendon reflexes

Laboratory: WNL

Important considerations for creating a SOAP note:

1. What problems can you identify with this patient?

2. What subjective/objective information in the case supports each of those

problems? Please list only information that pertains to each problem under each

problem.

3. What is your assessment and plan for each problem?

a. Provide pharmacological and non-pharmacological care (don’t forget to be

specific). Will you discontinue any medication that the patient is currently taking

and/or add any new medications?

b. Include your therapeutic goals for each problem (use the subjective and objective

information listed above to help you)

c. How will you monitor each problem and each medication included in your plan?

d. When will you suggest following up with the patient?

e. Is there any laboratory monitoring that will need to be conducted to assure the

safety of the patient?