- Students will be required to complete one SOAP (psych) note on a patient seen in the practicum setting each week.
- These need to follow the guidelines for writing SOAP notes (S = Subjective, O = Objective, A = Assessment, P = Plan) and include relevant history, physical findings, assessment, and interventions.
- Student is required to submit 2 different cases on the assigned patients in order to receive grade.
- Find Template for SOAP Note in the syllabus OR under TEMPLATES on the left hand navigator of blackboard.1
MOOD DISORDER
Chief Complaint
“I don’t want to feel this way anymore.”
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Order Paper NowPatient Demographic
Patient is a 36 year-old Caucasian, female Army Vet, divorced. She has three children: 21 y/o daughter, 8 y/o son, and 6 y/o daughter. She is currently unemployed but just recently got hired by a company that is contracted by Los Angeles International Airport (LAX).
History of Physical Illness
Most of the initial HPI was gathered from the documentation of the nocturnist, who is the on-call psychiatrist in the Emergency Department (ED). Vet came in on the night of 01/29/16 and was interviewed by this writer on 02/01/16. Per nocturnist, patient is a 39 y/o female veteran with past h/o PTSD, MDD, anxiety, MST who presents to the ED with anxiety, depression and thoughts of wanting to die. Patient reports that she has been severely depressed and scared over the past couple of weeks, and these feelings have progressively worsened over the past few days. She feels afraid, and has racing thoughts and nightmares. She reports there has been a couple of incidents that have set her off recently, but does not want to talk about them. She cannot leave the house anymore and can only stay in bed. She endorses feelings of wanting to die and cannot live with herself but denies any suicidal intent or suicidal plan. She states that she does not want to feel this way anymore and is here to seek help. She reports that she would like to get better so she can take care of her kids. She has not taken her medications for weeks as she was trying to seek employment a few weeks ago and was worried that they would not hire her due to her medications. She wishes to be admitted for treatment. Her kids are currently staying with her sister. Reports that she does have support from her sister and mom.
Upon interview this morning, Vet did not really want to talk much as she has her
blanket over her head. Interviewer attempted to confirm with her some of the information from the nocturnist’s notes on 1/29/16. Vet admits, “I don’t want to feel this way anymore.” When asked what she meant by this, she just cried. When asked if she has thoughts to harm herself, she continued crying but she denies any suicidal intent, denies suicidal plan. Said that she will never commit suicide because of her children. But admits to feeling guilty and worthless because of not being a good mother to her children. She has not eaten meals over the weekend except for drinking water as she states she has no appetite. Admits to nightmares, recurrent theme most of the time, but at times different. She does not want to elaborate on this. Admits hating crowds, “don’t like to be around people.” Admits that people are talking about her and wanting to harm her. She has been started on psych meds and she has been compliant with them since admission. Denies any substance abuse except for ETOH, admits to last drink on 1/17/16. Admits to nocturnist that she also used amphetamines a week prior to admission.
Past Psychiatric History
History of PTSD, Anxiety, Depressive d/o. Presentation upon admission: stressed because of brother being in jail for heroin use. Discharged Meds: Sertraline 50mg daily, Hydroxyzine 25 mg po every 4 hrs PRN
Substance Use History and Treatment
Per chart review, Vet has used amphetamines (per nocturnist’s notes) and ETOH (per interview with this writer) one week prior to admission. However, Vet does not want to answer this when asked in details. She only emphatically states, “this time there’s no drugs involved,” pointing out that she did not get admitted because of drug or ETOH use.
Medical History and Review of Systems
Per internist
Social History/Military History
Patient is a military Vet who was in the Army from November 11, 2010 to December 26, 2011 as an active duty Vet stationed in Somalia. Per records, she was raped in the military. She was honorably discharged. Overall years in the military together with Reserves is from 2008-2014.
Family History; Her parents are divorced but she still communicates with father and mother. She has a good relationship with mother and two older sisters. She has a brother but no communication from him as he is in and out of jail. Her highest degree of studies is high school. She is currently divorced from her ex-husband but states she talks to him minimally when it is about the children. Vet admits that ex-husband gives child support for their three children all of which are living with Vet. She reports that she worked in the airport last year for two years. Recently got a job also at the airport for baggage handling. However, Vet states that her orientation is this month and this was when she started becoming more anxious as the first day of work is fast approaching. She denies having any specific religion but states, “I believe in God.”
Mental Status Examination/Cognitive History
· Appearance; Vet has her head covered by her blanket, would just peek at times to this interviewer when she wants to clarify or negate a point.
· Her speech is low tone, soft, with paucity of speech most of the time.
· Her mood is, “I don’t want to feel this way anymore.” She has restricted affect, crying during the interview.
· Thought content contain thoughts of wanting to die, admits to PI of people wanting to harm/hurt her. Denies AVH, IOR.
· Her thought process is linear, but difficult to assess as she is guarded and selective with her disclosures as she states she doesn’t really want to talk much.
· Her insight to her hospitalization is poor to fair as she knows what brought her to the hospital but as of now does not want to talk to the providers to help her get better.
· Her judgment is poor as she is not eating and had used ETOH and methamphetamines prior to admission. MMSE is 30/30.
Diagnosis
296.31(F33.0) Major Depression
309.81 (F43.10) Anxiety Disorder
300.02 (F41.1) Posttraumatic Stress Disorders
305.00 (F10.10) Alcohol Use Disorder, Mild
Treatment Plan
· Labs had been ordered in ER and results were all within normal levels. However, UDS was not obtained thus I will order UDS and pregnancy test.
· Supportive approach will be done for withdrawals from amphetamines as Vet will just sleep off the effects of this substance. Since the Vet has not been fully cooperative with the interview, her provisional diagnosis for now is Major Depression.
· She was started back on her medications but at a lower dose because she has self-discontinued them for several weeks. She will be started on: Prazosin 1 mg for nightmares, Venlafaxine 37.5 mg for mood, Mirtazapine 7.5mg for sleep, Buspar 5 mg TID for anxiety, and Ambien 5mg PRN for sleep. Motivational interviewing will be utilized to explore her reasons for not eating, and to gather more information.
· Suicide risk assessment will be done every shift to assess for safety. She will be checked by nursing staff every 15 minutes during rounds. There are group therapy and individual therapy such as cognitive behavioral therapy and psychodynamic psychotherapy that will be beneficial for her (Wheeler, 2013). This will be explored with Vet if she is willing to participate.
· She is also followed up by outpatient psychiatry (OPP) MD, and her MD will be asked for collaboration of her care and plans for discharge.
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