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.
Aripiprazole (Abilify®) 10 mg at bedtime
Divalproex (Depakote®) ER 1000mg daily
Methylphenidate (Ritalin®) 20mg three times daily
Citalopram (Celexa®) 20mg at bedtime
GEN: slender female, tired-appearing
VS: BP 120/67, HR 85, RR 12, T 98, Wt 100lb, Ht 5’5”
NEURO: oriented to time, place and person; normal deep tendon reflexes
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
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?
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