Focused SOAP Note and Patient Case Presentation
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? Objective: What observations did you make during the psychiatric assessment? Assessment: Discuss patient mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms. Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session? In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking. Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
Focused SOAP Note and Patient Case Presentation
Patient particular’s
Initials: M.P
Age: 49years
Gender: Male
Race: Caucasian
Subjective Data
Chief Complaint (CC):
“I always feel pressured, and the feeling is worsening my sleep and focus.”
History of Present Illness (HPI):
The patient, M.P., is a 49-year-old male who claimed to have been suffering from anxiety and depressive disorder for more than 10 years, and he suspected it was a result of trauma. Recently, though, the symptoms have worsened, especially after he was detained, and the leading cause of the emotional problem is the fact that he cannot communicate with his daughter due to a protection order. He says that he has been overwhelmed by daily anxiety and emotionally getting worse by the day, and he cannot control his emotions. He says he is feeling sad and depressed; nonetheless, he does not entertain any thought of killing himself or others. He took fluoxetine and trazodone previously with good outcomes but stopped this medication recently, because of which his symptoms have worsened.
Past Psychiatric History
: Self-reported with major depressive disorder, generalized anxiety, and post-traumatic stress disorder. He was on fluoxetine 40 mg and trazodone 100 mg, which he had to stop when admitted to the health care facility. He reported that he was stable on these medications, but they were discontinued upon his hospitalization. He also mentioned taking hydroxyzine for anxiety. Although trazodone and hydroxyzine were verified upon intake, they were not restarted due to his detox process.
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Substance Use History:
M.P disclosed a history of substance use, including cocaine and alcohol, and has attended AA for treatment. He noted that he had been sober for 5 years during which he was able to buy a house and raise his daughter
Social History:
He was homeless but had a house at the time. He was sober, taking care of his daughter and working. At present, he cannot communicate with his daughter because they are under the parameters of the abuse-preventing order.
Family History:
There is a positive family history of psychiatric disorders such as depression and anxiety was observed in the client’s mother, brother, father and paternal aunt and uncle.
Patient’s Goals:
M.P. remembers a strained relationship with his daughter, a wish for custody of her, and the desire to stop drinking. He is willing to have dose changes on his medication to control his anxiety and depression.
Allergies:
Negative for drug allergies or adverse drug allergy history (NDA). No allergies to any food or the environment have been depicted in this frame.
Review of Systems (ROS)
General
: the patient has not lost or gained much weight and has no fevers or fatigue.
HEENT:
the patient has no headaches, visual disturbances, or difficulty hearing at any time.
Respiratory:
the patient has no shortness of breath or coughing.
Cardiovascular:
the patient has had no chest pain, palpitations, or edema for the last three months.
Gastrointestinal:
the patient has no emesis, diarrhea, or pain in the abdomen.
Genitourinary
: the patient has no dysuria hematuria and no alterations of urinary frequency.
Musculoskeletal:
the patient has no joint pain or stiffness.
Neurological
: the patient has no dizziness, syncope, or seizures.
Skin:
the patient has no rash, itching, or skin breakouts that change the skin’s texture.
Objective Data
Vital Signs
Blood Pressure (B.P.): 124/78 mmHg
Heart Rate (H.R.): 78 beats per minute (bpm)
Respiratory Rate (R.R.): 18 breaths per minute
Temperature (Temp): 98.2°F (oral)
Oxygen Saturation (SpO2): 99% on room air
Body Mass Index (BMI): 23.6 kg/m²
Physical Exam
General:
The patient is in a fair general condition without pallor, cyanosis, edema, and dehydration. He is fully oriented to person, place, and time.
Cardiovascular and Respiratory
: There are no cardiac murmurs or wheezing appreciated upon chest auscultation; heart and lung sounds were considered standard.
Musculoskeletal:
there are no limitations of joint movement of upper and lower limbs, no pain on pressure at any joint, and no sign of inflammation.
Neurological:
Ophthalmic, optic, facial, acoustic, glossopharyngeal, vagus, spinal accessory, and hypoglossal nerves are normal; no appreciable motor or sensory abnormalities are discerned.
Skin:
she has no visible skin rashes, lesions, or signs of infections.
Assessment
Mental Status Examination (MSE):
While doing the mental status examination, M.P. was well-turned, neat, and clean in the environment where they were dressed. On several occasions, he was agreeably behaved and was observed to be crying, showing how much he was under stress. His speech output was fluent, and his speech rate was average. M.P. had a depressed and anxious mood; his affect lacked the range of organized emotional expressions, and he was tearful in a way that corresponded to his emotional state. There were no apparent schizophrenia features, such as the presence of linear and coherent thinking without the presence of delusional or hallucinogenic ideas. He reported no suicidal or homicidal tendencies. No self-colored perceptual disturbances were observed. In the assessment, M.P. was fully oriented to person, place, time, and situation, implying intact cognition. He was able to give a reasonable account of his psychiatric problems and made reasonably good decisions, which included seeking medication for symptoms.
Risk Assessment
It is, therefore, essential to establish an updated suicidal risk assessment; in the evaluation, M.P. refuted having suicidal thoughts at the moment but mentioned hopelessness when he could not reach his daughter. However, it seems that M.P. felt deep emotional distress as a result of the communication difficulties he experienced during exacerbations. Still, at the same time, he was unequivocal that he did not want to die or harm himself. He denied past suicidal gestures with sharp objects, and not in the recent past had he attempted suicide. In addition, the M.P. denied homicidal or other paranoia and beliefs toward others, which is very important in evaluating his overall safety. Such fears were not present, and M.P. rejected the presence of any auditory or visual hallucination to eliminate significant perceptual abnormalities.
The depicted emotional concern for M.P. seems to be caused clearly by his imprisonment and the limitation of visitation rights as a father to his daughter, in particular. Nevertheless, he has continued to have contact with such a positive influence in his life, like the mother figure, and goals of the process, including staying sober and regaining the daughter figure. His desire to re-establish these aspects of his life, along with his willingness to cooperate, good orientation, and understanding of his situation, reduces his near-term risk of harm to himself or others. M.P. revealed eagerness towards improvement, hence an added confidence that does not consider him a high risk for suicide or violence.
Diagnostic Impression:
The first and foremost diagnosis related to M.P. is Generalized Anxiety Disorder (GAD), according to DSM-5-TR 300.02. This is well supported by the fact that the patient has had over six months of excessive, uncontrollable worry that has affected her ability to function and concentrate (Saramago et al., 2021). The DSM5-TR diagnostic criteria refer to GAD as excessive anxiety and worry about many events and activities for more days than not for at least six months. The individual finds it difficult to control the worry, and the anxiety is associated with at least three of the following symptoms: restlessness, fatigue, difficulty in concentration, irritability, muscle tension, sleep disorders, or the like (Sapra et al., 2020). Indeed, M.P. meets this diagnostic criterion as she reported restlessness, can’t concentrate, and sleeplessness. Troubling anxiety is uncomplicated and uninterrupted; it is not a specific sort of event feared.
Major Depressive Disorder (MDD) with Anxious Distress (DSM-5-TR Code: 296.23)
Although depression and anxiety may coexist in some patients, MDD with Anxious Distress was considered because anxiety is a close subtype to depression. This diagnosis is preferred when a patient has both depression as well as marked anxiety, like worry or restlessness during the depressive episode (Yang et al., 2024). For a patient to qualify for MDD diagnosis, the FPP must include at least five of the sadness symptoms for a two-week duration and any combinations of the anxious distress symptoms (Hopwood, 2023). This diagnosis is ruled out because the patient does not satisfy the basic signs of Major Depressive Disorder. They do not even have low mood, anhedonia, or other symptoms of core depression. However, their focus is anxiety, and there are no signs of the patient having developed both depressive episodes at the same time. This anxious mood rules out MDD with Anxious Distress.
Post-Traumatic Stress Disorder (PTSD): M.P.’s self-reported history of trauma though PTSD is compatible with the study criterion and concerning events that occurred to him during the hospitalization also established PTSD in this patient. Post-traumatic stress disorder is a psychiatric disorder, which presents intrusive thoughts, hyperarousal, avoidance behaviors, and negative alterations in mood and cognition in response to traumatic events (Stapleton, et al., 2023). Even though M.P. refused to give more information attached to traumatic events of his life, it is safe to conclude that M.P.’s trauma symptoms are present as he continues to experience complex PTSD common for patients after hospitalization. Probable PTSD delivered from past experiences in combination with the current influences of imprisonment and separation from the daughter also helped to enhance the emotional instabilities of the man.
Social Determinants Of Health
Healthy People 2030 defines the determinants of health as the conditions in which people are born, grow, live, work, and age, with determinants ranging from economic stability to education, social and community context, health and healthcare, and environment (Callaghan et al., 2023). About these determinants, we can say a lot, especially for a patient like M.P. with Generalized Anxiety Disorder (GAD). , for example, may affect her employability or the financial options available for her for treatment or even relate to her ability to manage stress or seek help from friends and family. Availability of health and health care is also considered necessary as there is the need to ensure that proper time is given to Human Health care providers, and services, especially the mental health providers, are essential for early diagnosis and treatment of anxiety. Based on this analysis, there is an opportunity for stress reduction activities to be part of an implementation plan for M.P., including mindfulness-based stress reduction or CBT group. Such programs assist in decreasing the symptoms of anxiety and, simultaneously, developing ways of coping with situations that cause relapses in the future. Presenting these classes in community centers or through online means would assist in eliminating such gaps and give patients such as M.P. the freedom to manage the situation.
When it comes to a discussion on patient education, the patient and, in this case, P.M., needs to be informed on self-care and pro-active management of mental health; hence, some points that will benefit her understanding include the ability to identify signs of worsening of anxiety, need to engage in some physical activity and lastly the importance of having a regular sleep schedule. Indeed, it is also essential to help her get the available mental health services, offline and online, to decrease the existing gaps in health disparities. Reducing factors that lead to inequalities like stigma, transportation, or financial aspects of reaching a mental health clinician can complement efforts in providing equal chances in psychiatric and mental health among the population.
Plan
The plan entails medication administration and counseling to explain the reason behind such treatment to the patient, M.P., and make him a key component in the treatment process.
Fluoxetine (Prozac) 10 mg per oral once a day for seven days, then increasing to 20 mg, increasing up to 40 mg as necessary. The pharmacy gives him a prescription for Fluoxetine, which will subdue his depression and his anxiety as well. Fluoxetine is an SSRI that widens the concentration of serotonin in the brain and may enhance mood, minimize stress, and eliminate hopelessness. Fluoxetine is especially helpful because it has been acknowledged to be useful in treating both MDD and GAD (Ampuero et al., 2024). The starting dose in general psychiatry is usually 10 mg to reduce side effects such as nausea, insomnia, or agitation. Still, it may be okay at the beginning of treatment for M.P. After seven days, the dose is titrated up to 20 mg, providing no discontinuation symptoms occur, up to 40 mg depending on his reaction. The desired outcome is to titrate M.P. up to an effective yet benign level of medication to effect symptom control without accessing profoundly toxic levels of the medication. Fluoxetine also has a comparatively long half-life with gradual onset effects. Hence, there are few chances of side effects, such as withdrawal symptoms, in cases when an individual skipped a dose.
Hydroxyzine 50 mg orally twice daily (morning and at night). The cause of anxiety during multi-tasking was treated with Hydroxyzine so that there would be no dependency on anxiolytics like benzodiazepines when it comes to the management of M.P.’s sleeping problems. Hydroxyzine is classified as an antihistamine with the anxiolytic effects of a sedative that calms due to inhibiting nerve excitation in some brain structures. This makes it an excellent quick-fix measure for anxiety and stress relief during the night when anxiety can be disruptive (Zhao et al., 2024). It does not have the dependency that is seen with other similar drugs like benzodiazepines; therefore, it cannot be relied on by people who Battaglia appreciates as having a history of emotional distress like M.P. Anti-anxiety effect during the day and sedatives at night are two issues that Hydroxyzine treats effectively without worsening M.P.’s condition with a dangerous medicine.
Any study with Trazodone was excluded regarding having Q.T. prolongation effect and being a Sedative. Sedating anti-depressant Trazodone was also excluded from the treatment regimen due to the possible risk of Q.T. prolongation, which could otherwise result in a dangerous heart rhythm. However, as Fluoxetine is also capable of causing an effect in the Q.T. interval, it is unsafe to take both Fluoxetine and Trazodone together as they can worsen this cardiac problem further. Third, the somnolent action of Trazodone provides an advantage in treating insomnia but causes additional issues in the general management of M.P., specifically when combined with Fluoxetine (Albert et al., 2023). Sedation could cause him not to be able to perform well during the day, and any cognitive side effects that Fluoxetine could cause would worsen. This decision can also be viewed in terms of the weighing of the risks against the therapeutic needs of the client, which has been a significant issue in the present case – M.P.;
Labs/Ancillary Tests
CBC with differential:
A complete blood count is helpful to screen for any hidden infection or disorders that may be related to the white or red cells since some of the psychiatric medications may alter the blood picture.
Lipid panel:
Fluoxetine is an SSRI, and its use can, therefore, lead to metabolic side effects like lipidemia. Consequently, it is relevant to monitor M.P.’s lipids to maintain his cardiovascular risk factor at the lowest level possible.
Hepatic function:
Fluoxetine is also metabolized in the liver; therefore, it is advised that M.P.’s liver enzymes should be expected before the institution of the above drugs. Supervision will also be relevant during treatment since the patient’s case will be constantly checked.
Thyroid function
: It bothers me that not only does hypothyroidism cause or worsen depressive and anxious symptoms, but it can also make a patient’s preexisting depressive and anxious symptoms worse.
C.T./MRI/X-ray:
If, for instance, M.P. complains of signs of neurological manifestation such as alteration of cognitive function, these tests might be recommended to exclude organic etiology.
EKG:
Due to the Q.T. prolongation seen with Fluoxetine, an ECG must be performed to determine M.P.’s baseline cardiac health and monitor for changes that would make the treatment safe.
Patient Education
M.P. was explained the pros and cons of the drugs prescribed to him. Specifically, fluoxetine dosing was stressed as crucial as it may take several weeks to notice the efficacy of the treatment. He was also told the possible side effects of Fluoxetine include sleep disturbances, gastrointestinal problems, and sexual dysfunction, and he was encouraged to report any issue, especially if its features are dizziness, palpitations, and increased anxiety. Hydroxyzine, uses was described as an equivalent of sleep and anxiety drugs that do not create dependency; recommendations on how to take doses that will not tire the reader during the day were given. M.P. was also informed of the decision to exclude Trazodone by looking at the side effects of Q.T. prolongation and sedation. He felt better knowing that his sleep and anxiety would be taken care of while on Hydroxyzine. M.P. was also briefly oriented regarding where to go for follow-up care, what lab tests to schedule, and when to come for an EKG. He was advised to go to his clinician if those symptoms worsen or if he develops side effects. Informed consent for the use of psychotropic drugs was sought and confirmed so that M.P. agreed with the management plan.
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