Clinical Analysis of Insomnia

Case Information:

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?

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