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Adjustment disorder SOAP Note Comprehensive Nursing Paper Example
| Criteria | Clinical Notes |
| Informed Consent | Informed consent given to patient about psychiatric interview process and psychiatric treatment. Verbal and Written consent obtained. Patient has the ability to respond and appears to understand the risk, benefits, and (Will review additional consent during treatment plan discussion). (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) |
| Subjective | Verify Patient Name: TY DOB: 17th June, 1986 Demographic: Caucasian Gender Identifier Note: Female CC: TY complains, “I feel hopeless and miserable”. “My condition followed my husband’s demise three months ago after a long battle with colon cancer.” HPI: The client complains of hopelessness and being miserable. Her condition began since her husband died three months ago.The client reports that she often feels sad and cries, hoping her husband could still be alive. Her status becomes worse when she goes to sleep at night and cannot fall asleep. She dreams of her husband beside her, only to wake up to the reality that he is gone and never coming back. She reports having a decreased appetite and has lost 7 pounds since. She cannot concentrate when depressed as her mind often wonders. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) She repudiates being suicidal or homicidal. SI/ HI/ AV: Denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors. Allergies: NKDFA. Past Medical Hx: Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury. Patient denies history of chronic infection, including Hep C, TB, HIV and MRSA. Surgical history: No surgical history reported Past Psychiatric Hx: Previous psychiatric diagnoses: None reported. Describes deteriorating course of illness. Previous medication trials: None reported. Safety concerns: History of Violence to Self: None reported History of Violence to Others: None reported Auditory Hallucinations: None reported Visual Hallucinations: None reported Mental health treatment history discussed: History of outpatient treatment: Not reported Previous psychiatric hospitalizations: Not reported Prior substance abuse treatment: Not reported Trauma history: Client Does not report history of trauma. Substance Use: Client denies use or dependence on nicotine/tobacco products. Client reports dependent of alcohol to cope with stressors. Client does not report abuse of or dependence on ETOH, and other illicit drugs. Current Medications: Prozac 20 mg PO qDay for depressive symptoms and anxiety. (Contraceptives): None Supplements: None Past Psych Med Trials: None reported Family Medical Hx: Family Psychiatric Hx: Substance use: None Suicides: None Psychiatric diagnoses/hospitalization: None Developmental diagnoses: None Social History: Occupational History: currently employed as assistant researcher in a pharmaceutical firm. Military service History: Denies previous military hx. Education history: completed bachelor’s degree in Biochemistry. Developmental History: None. Legal History: No reported legal issues. Spiritual/Cultural Considerations: Christian. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) ROS: Constitutional: No report of fever or weight loss. Eyes: No report of acute vision changes or eye pain. ENT: No report of hearing changes or difficulty swallowing. Cardiac: No report of chest pain, edema or orthopnea. Respiratory: Denies dyspnea, cough or wheeze. GI: No report of abdominal pain. GU: No report of dysuria or hematuria. Musculoskeletal: No report of joint pain or swelling. Skin: No report of rash, lesion, abrasions. Neurologic: No report of seizures, blackout, numbness or focal weakness. Endocrine: No report of polyuria or polydipsia. Hematologic: No report of blood clots or easy bleeding. Allergy: No report of hives or allergic reaction. Reproductive: Sexually active. No burning urination. No Pregnancy. Last menstruation, 09/10/2021.(Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) |
| Verify Patient: Name, Assigned identification number (e.g., medical record number), Date of birth, Phone number, Social security number, Address, Photo. Include demographics, chief complaint, subjective information from the patient, names and relations of others present in the interview. HPI: Past Medical and Psychiatric History, Current Medications, Previous Psych Med trials, Allergies. Social History, Family History. Review of Systems (ROS) – if ROS is negative, “ROS noncontributory” or “ROS negative with the exception of…” | |
| Objective | Vital Signs: Stable Temp: BP: 119/75 HR: 87 R: 17 O2: 97 Pain: None Ht: 5”8” Wt: 123lbs BMI: 18.7Kg/m2 BMI Range: Normal LABS: Lab findings WNL Tox screen: Negative Alcohol: Positive UDS: Negative Physical Exam: MSE: Patient is inattentive and fidgeting, appears withdrawn and in acute psychological distress, and fully oriented x 4. Patient is well dressed for the occasion. Presents good eye contact, blunted mood – appear anxious, sad, and unhappy., congruent with reported mood of “anxious”. Speech: Coherent and spontaneous. TC: no abnormal content elicited, denies suicidal ideation and denies homicidal ideation. Process appears linear, coherent, goal-directed. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) Cognition is grossly intact with limited attention span & concentration and significant fund of knowledge. Judgment appears fair . Insight appears fair The patient is able to articulate needs, is motivated for compliance and adherence to medication regimen. Patient is willing and able to participate with treatment, disposition, and discharge planning. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) |
| This is where the “facts” are located. Vitals, **Physical Exam (if performed, will not be performed every visit in every setting) Include relevant labs, test results, and Include MSE, risk assessment here, and psychiatric screening measure results. | |
| Assessment | DSM5 Diagnosis: with ICD-10 codes Adjustment disorder (AD) with depressed mood. ICD-10 code F43.21. TY presents diagnostic symptoms of AD with depressed mood such as (American Psychiatric Association, 2013). This is the primary diagnosis.Generalized anxiety disorder. ICD-10 code F41.1. TY presents the diagnostic symptoms of GAD such as anxiety and worry are associated with restlessness, fatigue, and difficulty concentration (American Psychiatric Association, 2013). This diagnosis is refuted. GAD symptoms should persist for at least six months. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) Moderate Major Depressive Disorder. ICD-10 code F33.1. TY presents moderate MDD diagnostic symptoms, including depressed mood, fatigue, and weight loss with feelings of emptiness, sadness, and hopelessness (American Psychiatric Association, 2013). This diagnosis is refuted since these symptoms are associated with the loss of a loved one. Persistent Depressive Disorder (PDD). ICD-10 code F34.1. TY presents PDD diagnostic symptoms, including poor appetite, sleeplessness, body fatigue, inability to concentrate, and hopelessness (American Psychiatric Association, 2013). This diagnosis is refuted. PDD symptoms should be persistent for at least two years. Alcohol-induced depressive disorder. ICD-10 code F10.24. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) TY presents symptoms associated with alcohol-induced depression, including depressed mood, distress, and impaired social functioning (American Psychiatric Association, 2013). This diagnosis is refuted since TY condition is not associated with alcohol use. Patient has the ability and appears to respond to psychotherapy and appears to understand the need for medications and is willing to maintain adherent. Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) |
| Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment. Informed Consent Ability | |
| Plan (Note some items may only be applicable in the inpatient environment) | Inpatient: Psychiatric. Discharge as per HPI. Safety Risk/Plan: Patient is found to be stable and has control of behavior. Patient poses no risk to self and others. Patient denies abnormal perceptions and does not appear to be responding to internal stimuli. Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: Discontinue Prozac 20 mg PO qDay for depressive symptoms and anxietyStart Citalopram 40 mg orally QAM and Clonazepam 1 mg orally TID for depression and anxiety respectively for 30 days. Celexa has been shown to contribute to a good mood by amplifying a patient’s living conditions (Chiarotti et al., 2017). Equally, Klonopin slows the electric activity of the CNS and reducing nervousness and agitation, promoting a sense of calm and relaxation (Wang et al., 2016). Start Zolpidem CR 5 mg orally QHS PRN for insomnia. Ambien slows the brain’s activity, allowing an individual to fall fast asleep (Bouchette, Akhondi, & Quick, 2021).(Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) Counselling referral for talk therapy. Talk therapy is considered a primary treatment for AD and provides emotional support, and allows a patient to regain previous self, learn about the stressful event, and stress-management/coping skills (Mayo Clinic, 2017).Education: Discussed the importance of medication and impact of alcohol abuse of health.Discussed medication side effects, when to contact office or report to ED Referrals: Psychotherapist for talk therapy Follow-up: Return to the clinic after 4 weeks, for further psychiatric assessment, medication response, and recommendation. ☒> 50% time spent counseling/coordination of care. Time spent in Psychotherapy 20 minutes Visit lasted 60 minutes Date: 10/26/2021 Time: 10am (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) |
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed.). American Psychiatric Publishing, Inc. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example)
Bouchette, D., Akhondi, H., & Quick, J. (2021). Zolpidem. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK442008/
Chiarotti, F., Viglione, A., Giuliani, A., & Branchi, I. (2017). Citalopram amplifies the influence of living conditions on mood in depressed patients enrolled in the STAR* D study. Translational psychiatry, 7(3), e1066-e1066. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) https://doi.org/10.1038/tp.2017.35
Mayo Clinic. (May 2017). Adjustment disorders.(Adjustment disorder SOAP Note Comprehensive Nursing Paper Example) Retrieved 17 September 2021, fromhttps://www.mayoclinic.org/diseases-conditions/adjustment-disorders/diagnosis-treatment/drc-20355230
Wang, S. M., Kim, J. B., Sakong, J. K., Suh, H. S., Oh, K. S., Woo, J. M., … & Lee, K. U. (2016). The efficacy and safety of clonazepam in patients with anxiety disorder taking newer antidepressants: a multicenter naturalistic study. Clinical Psychopharmacology and Neuroscience, 14(2), 177. (Adjustment disorder SOAP Note Comprehensive Nursing Paper Example)https://dx.doi.org/10.9758%2Fcpn.2016.14.2.177
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