القائمة الرئيسية

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 Here is the same case rewritten into three different formats you can choose from depending on your use:

✅ 1. Patient Handover Format (SBAR Style)

S – Situation:
37-year-old female with a history of asthma on Symbicort, presenting with new-onset emotional lability, insomnia, and palpitations for one week.

B – Background:

  • Known asthmatic on regular inhaler therapy (Symbicort).

  • Underwent gynecological surgery 4 years ago (details not available).

  • Married with 3 children.

  • Reports a tense and deteriorating relationship with her brother.

A – Assessment:

  • Acute onset of mood instability, intolerance towards children, poor sleep, and palpitations.

  • No signs of infection, substance use, or organic cause so far.

  • Possible differential includes anxiety disorder, adjustment disorder, or early depressive episode.

R – Recommendation:

  • Recommend psychosocial assessment and possible mental health referral.

  • Rule out hyperthyroidism and anemia with basic labs.

  • Supportive counseling and monitoring for worsening symptoms.

✅ 2. SOAP Note Format

S – Subjective:
Patient is a 37-year-old woman who reports a 1-week history of insomnia, palpitations, and feeling increasingly irritable, especially toward her children. She acknowledges increased stress related to a strained relationship with her brother. She denies chest pain, fever, or substance abuse. She is concerned about her emotional control and sleep quality.

O – Objective:

  • Vitals: WNL

  • General: Alert, cooperative, mildly anxious.

  • Chest: Clear breath sounds, no wheeze.

  • Cardiovascular: Regular rate and rhythm.

  • No signs of thyromegaly, tremor, or sweating noted.

A – Assessment:

  • Asthma, stable on Symbicort

  • New-onset emotional dysregulation and insomnia

  • Likely adjustment disorder vs. generalized anxiety vs. subclinical depression

  • Consider endocrine/metabolic triggers (e.g., thyroid disease)

P – Plan:

  • Labs: CBC, TSH, FT4

  • Psych referral for further evaluation

  • Sleep hygiene counseling

  • Consider short-term anxiolytic if symptoms worsen

  • Schedule follow-up in 1 week

✅ 3. Referral Letter Format

To: Psychiatry Department / Clinical Psychologist
From: Family Medicine Clinic
Re: Referral – Evaluation of Emotional and Behavioral Symptoms

Dear Colleague,

I am referring a 37-year-old married woman, mother of three, with a known history of asthma on Symbicort, for further assessment and support. She presents with a 1-week history of increasing emotional reactivity, intolerance toward her children, insomnia, and palpitations. There is no history of chest pain, substance use, or acute stressors other than a longstanding and currently strained relationship with her brother.

Her symptoms have raised concern for a possible adjustment disorder, anxiety spectrum disorder, or mood disturbance. Physical examination and vitals are within normal limits. She underwent gynecological surgery 4 years ago and reports no other significant medical issues at this time.

Kindly assess and advise on further management.

Best regards,
Dr. [Your Name]
Family Medicine

Would you like this case translated to Arabic as well? Or adapted for a teaching slide, OSCE, or exam MCQ?

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