Unit 12 Assignment – Clinical: SOAP Note

Unit 12 Assignment – Clinical: SOAP Note – Each week students will choose one patient encounter to submit a Follow-up SOAP note for review…

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Unit 12 Assignment – Clinical: SOAP Note

Paper details

Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.

Follow the rubric to develop your SOAP notes for this term.

The focus is on your ability to integrate your subjective and objective information gathering into the formulation of diagnoses and the development of patient-centred, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions.

At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.

Note: Grades of Incomplete on this assignment will result in a clinical failure.

Template and sample attached

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Solution

Unit 12 Assignment – Clinical: SOAP Note

Criteria Clinical Notes

Informed Consent Informed consent was given to the patient about the psychiatric interview process and psychiatric/psychotherapy treatment. Verbal and Written consent was obtained. The patient the ability/capacity to respond and appears to the risk and benefits of the treatment plan.

Subjective

Verify Patient

Name: Walter Grant
DOB: 23/05/1997
N/A
Minor: Accompanied by: Friend
Demographic: The patient is a 24-year-old male accompanied to the facility by his friend.
The patient presents for treatment related to increased heroin abuse and is voluntarily admitted.

The patient is a final-year student in college. He lives in a rental apartment away from his parents. He has recently broken up with his girlfriend of five years, mainly due to his addiction problems.

Gender Identifier Note: Male
CC: “I think I am losing my mind.”
HPI: WG is a 24-year-old male with a history of substance use. He admits heroin use for close to a year now. He reports that his roommate introduced him to heroin and methane but claims to have stopped using methane. The patient claims to have smoked a joint when they broke up and denies using it again. He admits that he mainly takes heroin to reduce his anxiety (Fendrich et al., 2019).

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GW admits that he went into depression after being discontinued from his studies due to disciplinary issues three months ago, which worsened his addiction. He reports that the depression has worsened over time, and he now has suicidal thoughts. He is currently on antidepressants, but he does not follow the dosage as prescribed. He denies any allergies.

He rarely interacts with other people, except for a few friends. He loves painting and making music. In this case, he spends most of his time alone working on his art. He is the firstborn in a family of four but does not relate well with his family members. His parents are separated, and his three siblings live with his mother.

Pertinent History in the record and from the patient: yes
Previous medication trials: .
Safety concerns:
History of Violence to Self:
History of Violence to Others: NA
Auditory Hallucinations: confirms.
Visual Hallucinations: confirms
Mental health treatment history discussed:
History of outpatient treatment: unknown at this time
Previous psychiatric hospitalizations:
Prior substance abuse treatment:
Trauma history: The patient

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Substance Use: Client
The client
Current Medications: Antidepressants
(Contraceptives): N/A
Supplements: N/A
Past Psych Med Trials: unknown at this time
Family Medical Hx: Unknown
Family Psychiatric Hx: Father, bipolar disorder.
Social History:
Occupational History: Not employed
Military service History: Denies previous military hx.
Education history: In his final year on campus
Developmental History:
(Childhood History include in utero if available)
Legal History: , .
Spiritual/Cultural Considerations: .
ROS:
Constitutional: .
Eyes: .
ENT:
Cardiac: .
Respiratory: .
GI: .
GU.
Musculoskeletal:
Skin.
Neurologic: Endocrine: .
Hematologic:
Allergy:
Reproductive:

Objective

Vital Signs
Labs: No blood work currently available.
Physical Exam:
MSE:

The patient mood is depressed and affects congruent.
Patient avoidant of eye contact.
The patient has problems with expressing himself
The patient has normal motor activity.
The patient appears unkempt.
Reports auditory and visual hallucinations.

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Assessment

DSM5 Diagnosis: with ICD-10 codes
The patient is suicidal and has severe depression.
Patient meets DSM-V criteria for:
Heroin use disorder F11.20
Cannabis use disorder F12.9
Methane use disorder K90.89
Suicide ideation R45.81
Differential Diagnoses
Cannabis-induced psychotic disorder F12.259
Heroin induced psychotic disorder F19.251
Major depressive disorder F32.3
Major Depressive Disorder F32.3- Confirmed

The patient suffers from a major depressive disorder caused by substance abuse and changes in his life, such as inadequate social life, breaking up with his girlfriend, and discontinuation from his studies. While he presents a lack of social interest, increased stay by himself, issues with his girlfriend and school, he is eligible for a major depressive disorder diagnosis.

Using the DSM-5 criteria for MDD, the patient has a depressed mood, weight loss, lack of interest in what he previously regarded as entertaining, such as making music and drawing, insomnia, blaming himself for the breakup, reduced concentration, and fatigue, confirmed the presence of major depressive disorder.

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The depression needs to be addressed as it is also connected to suicidal thoughts. Some effective treatment options for major depressive disorder are cognitive behavioral therapy and antidepressants. Specifically, the patient ruled out therapy due to costs.

In this case, the treatment options available for the patient are selective serotonin reuptake inhibitors (SSRIs), including Zoloft, Celexa, Lexapro, Prozac, and Paxil (Cohen & DeRubeis, 2018). The most appropriate treatment for the patient is Lexapro, as it is considered the most effective and tolerable in reducing depressive symptoms. In this regard, there are higher chances of the patient recovering with the least side effects.

Heroin Induced Psychotic Disorder F19.251- Confirmed

The heroine-induced psychotic disorder was confirmed following his high levels of intoxication and delusions (Ratycz et al., 2018). He has been using heroin for approximately one year, and his intake has increased over the recent past following his school issues and problems with his girlfriend. Some of the most effective treatment options are medical or behavioral therapy for heroin abuse (Ratycz et al., 2018).

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In this regard, the available treatment for the patient is anxiolytic such as benzodiazepine and methadone or antipsychotics. The most effective treatment is methadone, which is more affordable based on the patient’s condition. Nonetheless, the patient is willing to be admitted to the facility and cooperate in treatment for at most two months.

Cannabis-Induced Psychotic Disorder- Refuted

Although the patient had smoked marijuana after the breakup, the diagnosis indicates that the effect faded out, and he doesn’t present any cannabis-induced psychotic disorder symptoms.

Treatment Goals:

Major depressive disorder- to help reduce suicidal thoughts.
Heroine-induced psychosis disorder- to stop heroin intake to prevent anxiety.
Informed Consent Ability: The patient appears to understand the need for medication and is willing to adhere to the treatment and care plan. Also reviewed were the risks and benefits of the treatment options.

Informed Consent Ability: Patient has ability/capacity appears to respond to psychiatric pharmacological and psychotherapy interventions and appears to the need for medications/psychotherapy and ready and willing to adhere to the recommended treatment and care plan.

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Plan

(Note some items may only be applicable in the inpatient environment)

Inpatient:

Safety Risk/Plan: The patient is and of behavior. The patient likely poses a risk to self and a risk to others at this time.
The patient abnormal perceptions and appear to be responding to internal stimuli. Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic:

Patient to create safety contract with a therapist.
Patient to be placed on 72-hour hold.

Pharmacological interventions
Pharmacological
Medications:
Phenelzine 20 mg PO daily for depression
Olanzapine 10 mg PO QHS for depression
Methadone 20mg PO daily for heroin suppression
Buspirone 10 mg PO TID for anxiety

Education, including health promotion, maintenance, and psychosocial needs

The patient will be educated about the medication regimen, including indications, side effects, and adverse reactions. For instance, the patient may experience nausea, constipation, drowsiness, and lightheadedness while on medication (Fendrich & Becker, 2018). The patient will be educated on the adverse effects of substance abuse and how to live a sober life.

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Referrals: The patient will be referred to therapy for Cognitive Behavioral Therapy for depression and anxiety (Cohen & DeRubeis, 2018). He will be referred to a support group for previously addicted persons to help abstain.

Follow-up TBD upon closer to discharge

Following the patient’s discharge, he will follow up every four weeks to check his progress. This will help perform physical and lab tests to address any abnormal findings on time.

Date: Time:

References

• Cohen, Z. D., & DeRubeis, R. J. (2018). Treatment selection in depression. Annual Review of Clinical Psychology, 14(1), 209-236. https://doi.org/10.1146/annurev-clinpsy-050817- 084746
• Fendrich, M., & Becker, J. (2018). Prior prescription opioid misuse in a cohort of heroin users in a treatment study. Addictive Behaviors Reports, 8, 8-10. https://doi.org/10.1016/j.abrep.2018.04.001
• Fendrich, M., Becker, J., & Hernandez-Meier, J. (2019). Psychiatric symptoms and recent overdose among people who use heroin or other opioids: Results from a secondary analysis of an intervention study. Addictive Behaviors Reports, 10, 100212. https://doi.org/10.1016/j.abrep.2019.100212
• Ratycz, M. C., Papadimos, T. J., & Vanderbilt, A. A. (2018). Addressing the growing opioid and heroin abuse epidemic: A call for medical school curricula. Medical Education Online, 23(1), 1466574. https://doi.org/10.1080/10872981.2018.1466574

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