soap note response
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
M’balu M. Kebbi
Subjective:
CC (chief complaint): Pt, N.A, presents to the clinic during an initial visit with complaints of worsening dysphoric mood, decreased concentration, excessive worry, and nervous/anxious behavior. She reports that her symptoms are gradually worsening, stating that her current medications are ineffective in treating/managing her symptoms.
HPI: Pt, N.A, is a 70 year-old Caucasian female who presents for an initial psychiatric evaluation for medication management, related to dysphoric mood. Pt states she has not felt happy in a very long time since she was a teenager. She reports decreased concentration, irritable mood and behavior, excessive worrying, nervous/anxious behavior and insomnia. Pt reports that her symptoms started at the age of fifteen when her mother became sick (passed when patient was sixteen), and have worsened over the years to the point that it interrupted her nursing schooling. Pt reports to have been initially diagnosed with ADHD as a teenager and was prescribed Ritalin which she referred to as “Heaven on earth” and reports that discontinuation of this medication exacerbated her symptoms which pt states as cause for her job terminations. She reports increased worsening of symptoms following loss of several jobs due to her constant worry of making a mistake, and reports feelings of guilt as a mother to have done nothing about it. N.A reports ongoing feelings of emptiness, nervouseness, increased agitation, depressed and irritable mood swings, and feelings of worthlessness.She reports that her concentration has declined significantly in recent months. Pt reports to have moved to a senior facility and expresses frustrations with current living situation. She reports feeling more anxious around other residents, and is seeking to move to the first floor by the exit area, to minimize frequent interaction with others. Furthermore, pt reports feeling increasingly irritable and has difficulty in other residents wanting medical advice from her, and is convinced they know of her previous practice as an RN, making her more irritable with other residents, and is convinced that some residents rely on her for medical advise and interventions, given her history of being a nurse, which she states bothers and irritates her even further. She reports ongoing difficulty in effectively communicating with other residents, given her ongoing irritability, and admits to being socially awkward, which makes her avoid going to the common area in her facility, often leading to self-isolation. Patient verbalized loss of interest in doing once pleasurable things, low energy and ongoing depressed mood. She reports that her current medications prescribed are probably ineffective in treating her symptoms, hence her evaluation for medication review and possible adjustment/changes. N.A denies thoughts of suicide or wanting to hurt others. She endorses to be currently taking psychotrophic medications, but is convinced that they’re ineffective in treating/managing her symptoms, which she reports as worsening.
Substance Current Use: N.A denies past, or current use of tobacco, alcohol, vaping, illicit drugs or any substance use. None found on record.
Past Psychiatric History: N. A reports to have initially started having mental health concerns at the age of 15, after her mom became sick, was hospitalized and later passed when patient was 16 years old. She reports that her dad started to date afterwards, which caused her intensed stress as she was not prepared, and began having hallucinations at age 18. She also endorsed to have developed psychosis right after she graduated from high school in 1970, which led to her putting a hold on initially going to nursing school. N.A reports participating in psychiatric treatment/psychotherapy from 1988 to 1997, with an interruption in services until last seen in August of 2021, and was recently seen for counseling. Patient reports treatment with Electroconvulsive Therapy (ECT), in an attempt to reverse symptoms related to her mental illnesses. Patient reports to have been tested and diagnosed with ADHD, informs to have been treated with Ritalin which patient refers to as “Heaven on Earth” the discontinuation of which patient attributes to the worsening of her symptoms which she believes as reason for job terminations. N.A reports period of time when she was not sleeping, and recalls to have taken off driving, causing her to get pulled over with suspicion.
Caregivers: Patient reports to have been treated by a psychiatrist from 1988-1997, and in August of 2021, and a few times in February and March of 2022 by a Psychiatrist, and was most recently in the past month for counseling. Pt also reports having a PCP whom she sees as needed.
Hospitalizations: N.A reports to have had numerous psychiatric hospitalizations and several outpatient services at a local psychiatric clinic, many years ago.
Psychotherapy or Previous Psychiatric Diagnosis: Patient reports prior paticipation in psychotherapy intermittently between 1988-1997, and reports to have been diagnosed with ADHD at age 18. She reports possible diagnosis with early onset dementia in past years.
Family
Psychiatric/
Substance
Use
History: No reports of family psychiatric or substance use, none found on file. Patient reports her mom having had brain cancer which metastatised, leading to her passing within seven months.
Psychosocial History: Patient, N.A is a 70-year-old Caucasian female who reports to have been raised by both parents, and had a younger brother who passed away from a chronic illness, and a half younger sister who resides in Colorado. Patient reports to have been married twice, and has two adult sons from her first marriage. She reports to have initially earned her LPN, and later went on to graduate as a Registered Nurse. N.A reports to have worked in hospital settings as a nurse for over many years, and worked part time at a local clinic and at a retail store, and later served as a volunteer at an adult daycare. Patient reports currently being on Social Security Disability Insurance (SSDI). N.A reports to have been promiscuous in 1973/74, but is currently divorced and not currently in a romantic relationship. She reports to have been beaten with a belt by her dad, but otherwise denies any sexual abuse or other trauma not already mentioned. Patient denies any active legal issues, and denies past or current drugs, alcohol or other illicit drug use.
Medical
History: Hyperlipidemia, Hypertension. No other medical illnesses or history reported or found.
·
Current
Medications: Amlodipine (Norvasc) 2.5 mg tablet, once daily by mouth for hypertension.
· Atorvastatin (Lipitor) 10 mg tablet one tablet daily for high cholesterol.
· buPROPion (Wellbutrin XL) 300 MG 24 hr tablet once daily for depression.
· busPIRone (BUSPAR) 15 MG table once tablet two times daily for anxiety.
· trazodone (DESYREL) 100 MG tablet take 4 tablets (400 mg) at bedtime for depression.
· Triamterene-hydrochiorothiazide (MAXZIDE-25) 37.5-25 MG per tablet take one tablet once daily for hypertension.
· Venlafaxine HCI (EFFEXOR -XR) 150 MG 24 hr Capsule. Take 2 capsules (300 mg total) by mouth once daily for anxiety/depression.
· Venlafaxine HCI (EFFEXOR -XR) 75 MG 24 hr Capsule. Take 1 capsule by mouth once daily for anxiety/depression.
·
Allergies: No known medication, food or seasonal allergies.
·
Reproductive
Hx: No reports of current sexual activity. Patient has two adult sons. No indications, concerns or reports of sexually transmitted diseases.
ROS:
·
GENERAL: Pt is alert, oriented x 4 and cooperative with interview. No reports of recent significant weight loss or gain.
·
HEENT:
Head: Normal size and shape, no deviation in cercomference.
Eyes; No visual difficulty or loss, no discharge.
Ears: No hearing difficulty or loss.
Nose: No sinusitis, no loss of smell or drainage.
Throat: No tonsilitis, no difficulty swallowing.
·
SKIN: No skin tags, no open areas
·
CARDIOVASCULAR: No heart murmur, no palpitations or chest pain.
·
RESPIRATORY: No shortness of breath or difficulty breathing.
·
GASTROINTESTINAL: No nausea, no vomiting, no abdominal bloating, pain or tenderness.
·
GENITOURINARY: No urinary incontinence or retention.
·
NEUROLOGICAL: No numbness or tingling in hands and feet, no headaches, no dizziness or fainting.
·
MUSCULOSKELETAL: Difficulty with ambulation. Uses walker.
·
HEMATOLOGIC: No abnormal bleeding or bruising, no anemia.
·
LYMPHATICS: No swollen lymph nodes.
·
ENDOCRINOLOGIC: No polyuria, no intolerance to cold or heat.
·
Psychiatry: Positive for decreased concentration, agitation and dysphoric mood.
Objective:
Physical
Exam: Vitals: BP: 148/88, Pulse: 72, RR: 20, Wt 267 lbs, BMI 41.82 kg/m2.
General: Pt is alert, oriented x 4, and cooperative with this exam. She denies any recent significant weight gain or loss, and shows no evidence of physical distress.
HEENT:
Head: Negative for abnormal size or shape.
Eyes: Negative for visual loss or difficulty.
Ears: Negative for difficulty hearing or deafness.
Nose: Negative for loss of smell or sinusitis.
Throat: Negative for difficulty swallowing or tonsilitis.
Skin: Negative for open areas or sores.
Cardiovascular: Negative for chest pain or heart palpitations.
Respiratory: Negative for shortness of breath or difficulty breathing.
Gastrointestinal: Negative for abdominal pain or tenderness, negative for nausea or vomiting.
Genitourinary: Negative for incontinence or retention.
Neorological: Negative for headaches, dizziness or fainting.
Musculoskeletal: Positive for difficulty with ambulation. Uses walker.
Hematologic: Negative for abnormal bruising or bleeding.
Lymphatics: Negative for palpable lymph nodes.
Endocrinologic: Negative for polyuria, negative for intolerance to heat and cold.
Psychiatric: Positive for decreased concentration, agitation, depressed and dysphoric mood.
Diagnostic
results: This initial evaluation involves a 70-year-old Caucasian female who presented to be seen, with complaints of worsening depressed and dysphoric mood, increased agitation, excessive worry, an anxious/nervous behavior and insomnia. Given her presentations, N.A would benefit from an initial thorough psychiatric evaluation that entails history-taking to establish a baseline which would serve as future reference to determine treatment progress, disease progression and response to treatment (Rifkin, et al., 2015). CBC, Renal function panel and BMP from recent PCP visit are normal, urine drug screen negative for Cocaine, THC, Methamphetamines, Urinalysis negative for UTI and hematuria. Additional laboratory test that may be important is a TSH. Evidence shows that mood symptoms including anxiety, irritability and nervousness could be associated with an overactive thyroid function, a condition known as hyperthyroidism, wherein an underactive thyroid function, a condition known as hypothyroidism could also cause depression and unusual tiredness (MayoClinic).
Assessment:
Mental
Status
Examination: N.A, is a 70-year-old Caucasian female who’s alert, oriented and cooperative with the interview. Patient is adequately groomed and appears stated age. She makes fair eye contact, her speech volume is normal with appropriate content, her rate is rapid. Her thought process is circumstantial, with appropriate content. She denies suicidal and homicidal thoughts, no hallucinations or delusions apparent. Her insight is fair, with no apparent impairment of short-term or long-term memory. Her concentration is fair, with fund of memory consistent with her education. Her mood is anxious, affect is consistent with mood.
Diagnostic
Impression:
Mild
Episode
of
Recurrent
Major
Depressive
Disorder: This is a mood disorder that is characterized by a depressed and irritable mood, loss of interest in pleasurable things and low energy, with symptoms that persists most of the day on a daily basis for at least two consecutive weeks, wherein symptoms are either new or have clearly worsened and significant enough to cause clinical distress or impairment in social, occupational or other crucial areas of functioning (Abuse, & Administration, 2016). N.A’s reported symptoms of an ongoing depressed mood, irritability and loss of interest in once pleasurable activites are consistent with the DSM-5 criteria for major depressive disorder, making it a suitable differential diagnosis for her.
Generalized
Anxiety
Disorder (
GAD): This disorder pertains to excessive worry that occurs on more days than not for at least 6 months about several events or activities, wherein the person finds it difficult to control the worry, with characteristic symptoms including restlessness, fatigue, difficulty concentrating, irritability, and sleep disturbances, with physical symptoms causing clinically significant distress or impairment in social, occupational or other crucial areas of functioning (Abuse, & Administration, 2016). Additionally, the disturbance is not attributed to any direct physiological effects of a substance, drug or medication, or a general medical condition (Abuse & Administration, 2016). N.A endorsed ongoing symptoms pertaining to sleep disturbance, excessive worry, low energy and decreased concentration to an extent of interfering with her social interactions and functioning, causing her psychological distress and unease, which makes this a credible diagnosis for her ongoing condition.
Schizoaffective
Disorder,
Unspecified
Type: This is a mental health disorder that has a bipolar type and depressive type, with characteristic combination of schizophrenia symptoms such as delusions or hallucinations, and mood disorder symptoms such as depression or mania (National Library of Medicine, 2022). The mood component of this disorder with depressive symptoms, along with N.A’s admission of prior psychotic symptoms including hallucinations makes this a suitable diagnosis for N.A. Evidence shows that if untreated, people with schizoaffective disorder may have problems with difficulty maintaining a job, as well as functioning in social situations which may lead to loneliness, perhaps an explanation why N.A finds it awkward to socialize with others which leads to self-isolation and an increased likelihood of loneliness (MayoClinic).
Reflections: This case is reflective of a 70-year-old Caucasian female who presents with complaints of dysphoric and irritable mood, decreased concentration, excessive worry and difficulty sleeping, among other complaints. Pt reports that her symptoms are long-standing, and gradually worsening to the extent she gets easily irritable and agitated with other people, has been avoiding social gatherings and often self-isolates. She reports that her current medications are ineffective in treating/managing her symptoms, hence the reason for the visit for medication review, and possible modification. It’s apparent that the patient’s symptoms are interfering with her daily functioning and overall quality of life, making it crucial for prompt intervention. To facilitate this, a comprehensive assessment that includes history-taking, review of laboratory test results and other diagnostic tests and evidence would play important role in trying to pinpoint any medical condition or family history the patient may have that could be contributing to her symptoms. It’s important to note that there are certain medical conditions that could initially present with psychiatric symptoms, hence the need to perform thorough comprehensive examination and review of test results to rule out underlying medical etiology that may be manifesting as psychiatric disorders (Cambridge University, 2018). Ultimately, the goal is to collaborate with the patient to formulate a treatment plan aimed at improving and managing her symptoms in ways that would enhance her daily functioning and overall quality of life. The clinician did a great job in asking the patient specific questions that pertained to her family dynamics and in asking the patient open-ended questions which ilicited further detailed responses, rather than questions that prompted yes or no responses. I would have loved for the patient to have shared more insights about how her past traumas affected her personally, and whether she has nightmares related to her past, and how effective she finds counseling in helping her heal, or does it cause negative triggers to reflect on her past? By asking such questions and getting appropriate responses, it could help identify further therapeutic interventions and coping strategies the patient could benefit from, and determine the effectiveness of treatment she may be receiving.
Case Formulation and Treatment Plan:
Given the patient’s complaints and presentations, N.A would benefit from both pharmacological and psychotherapeutic interventions. Evidence shows that psychiatric medications influence brain chemicals that are responsible for regulating emotions and thought patterns, and that the combination with psychotherapy potentiates its effectiveness, wherein medications helps to reduce symptoms, allowing the patient to participate more in therapy and thereby fostering effectiveness of other methods of treatment (National Alliance on Mental Illness). In addition, research shows that the combination of medications and psychotherapy is more effective in treating depressive symptoms, compared to treatment with medications alone, in that they complement each other, given their varying effects on the brain (Harvard Medical School, 2020).To facilitate this, we will start patient on Quetiapine (SEROQUEL) 50 MG Tablet. Take 3 tablets (150 mg total) by mouth at bedtime for depression. Continue taking prior listed medications as ordered. Continue psychotherapy sessions/counseling as scheduled. Return to clinic in two weeks for follow up to assess medication effectiveness and symptom management. Educated patient on mendication use, benefits and potential risks and side effects, reviewed possible tetragenic effects of medications, encouraged on medication compliance as directed, educated on the need for abstinence from alcohol and substance use while taking medications, reviewed effects of substances on mental health. Educated patient and encouraged on healthy eating, sleeping habits and activity as tolerated, discussed coping strategies, provided patient with emergency contacts, crisis hotlines and mental health community resources, encouraged patient to use recommended services as needed, provided time for patient to ask questions, make clarifications and provide feedback. Pt verbalized understanding of instructions and teaching provided. Maintained patient privacy and confidentiality throughout, and ensured patient of her rights. It’s important to note that Patient returned in two weeks for follow up and reported noticing “big improvement” with anger in the past week, and informs that she recently attended a holiday event at her facility with good outcome, something she had avoided and not done in the past. She also reports that she’s not as irritable as before, and is interacting and responding better to people in recent weeks since the medication change. Ultimately, the patient reports improvement in her symptoms and is seemingly responding well to therapeutic endeavours, enablying her to live a more functional and productive life, geared towards mental wellness!
Questions: In closing, my three questions are; Given the patient’s symptomatic presentations, do you agree with my primary differential diagnosis of Major Depressive Disorder? If yes, why? If no, why not? My second question is what coping strategies would be appropriate for this patient, given her conditions? Finally, do you agree with the addition of Seroquel to the patient’s medication, why or why not?. Remenmer, the goal is to provide the patient with treatment options aimed at improving her mental wellbeing and overall health outcomes.Thank you.
References
Abuse, S., & Administration, M. H. S. (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health.
Harvard Medical School, (2020). Medication or therapy for Depression? Or Both?.
https://www.health.harvard.edu/staying-healthy/medication-or-therapy-for-depression-or-both
National Alliance on Mental Illness. Mental Health Medications.
https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications#:~:text=They%E2%80%99re%20usually%20more%20effective%20when%20combined%20with%20psychotherapy.,an%20individual%20to%20engage%20more%20in%20talk%20therapy
.
Rifkin, R. M., Abonour, R., Terebelo, H., Shah, J. J., Gasparetto, C., Hardin, J., … & Durie, B. G. (2015). Connect MM registry: the importance of establishing baseline disease characteristics. Clinical Lymphoma Myeloma and Leukemia, 15(6), 368-376.
Mayoclinic.org. Thyroid Disease: Can It Affect A Person’s Mood?
https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/expert-answers/thyroid-disease/faq-20058228
Mayoclinic.org.Schizoaffective Disorder.
https://www.mayoclinic.org/diseases-conditions/schizoaffective-disorder/symptoms-causes/syc-20354504
National Alliance on Mental Illness. Mental Health Medications.
https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications#:~:text=They%E2%80%99re%20usually%20more%20effective%20when%20combined%20with%20psychotherapy.,an%20individual%20to%20engage%20more%20in%20talk%20therapy
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