Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example

Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example

Subjective:

CC (chief complaint): “Mom says I get moody this time of year, every year. I don’t know. Maybe.” 

HPI: Ms J.H. is a 19-year-old caucasian female referred for counselling by her mother, who is worried about her. Ms J.H. does not feel great. She feels down. “I am not doing so well.” She reports that the school is okay but left the program she was taking. She denies that the courses are challenging since she understands everything. She reports that the teachers are getting to be “a bit of pain,” and the classes are not “lustrous.” She reports being in a special business program in which they are to propose a company and can’t get the assignment done. She is also late in another two projects. She reports trouble concentrating; she can read and forgets what she has read. Ms J.H. cannot remember what she has learned when she leaves the classroom. The client reports having irregular eating and sleeping patterns. She has gained ten pounds and slept through five of her class this month. She reports making friends quickly at the school, as the people were fun when she arrived in August. She did most things with her friends, went to concerts, and shows, hung out, and had much fun. However, her friends are presently annoying to her. They are dull and play board games, yet she wants to go outside. The weather has also made it impossible to hang out. She frets in fall and winter. She likes summer, the beach, and convertibles, which she can’t do now. Ms. J.H. dislikes winter because it’s dark, grey, and miserable. During this time, the city changes, and it is no longer the beautiful city she loves. (Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Past Psychiatric History:

• General Statement: This is the first time the patient is entering treatment.
• Caregivers (if applicable): N/A
• Hospitalizations: No report of previous hospitalization. No history of suicide or homicide ideation. No history of self-harm behaviors.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)
• Medication trials: No previous psychotropic medication has been tried.
• Psychotherapy or Previous Psychiatric Diagnosis: No previous psychotherapy or psychiatric diagnosis was reported.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Substance Current Use and History:  No history of current or past substance abuse or withdrawal complications was reported.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Family Psychiatric/Substance Use History: No history of psychiatric or substance use illness in the family. No history of suicides.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Psychosocial History: The client grew up and was raised by both parents in South Carolina her whole life. Has two brothers and a sister. Currently lives together with two female roommates in off-campus housing. The client is a full-time student and not employed. The client is single with no children. She is pursuing a special business undergraduate program in Boston, MA. A client is an outgoing person. She easily makes friends and prefers summer, going to the beach, and enjoying convertibles. She also likes having fun with friends and going to concerts and shows. No legal history. No childhood or adulthood history of trauma. No history of violence at home, in school, or the community.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Medical History: No history of illnesses or surgeries reported. No history of headaches or injuries was reported.

• Current Medications:  No current medications.
• Allergies: NKFDA
• Reproductive Hx: Reproductive history not reported.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

ROS:

• GENERAL: Reports 10 lbs weight gain. No fever or chills.
• HEENT: No visual changes. No hearing loss. No nasal congestion. No sore throat.
• SKIN: No itching or rash.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)
• CARDIOVASCULAR: No chest pain or discomfort. No palpitations or edema.
• RESPIRATORY: No dyspnea. No cough or sputum.
• GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain.
• GENITOURINARY: No urination hesitancy, urgency, or odor. 
• NEUROLOGICAL: No syncope, paralysis, headache, numbness, or dizziness.
• MUSCULOSKELETAL: No change in bladder or bowel control.
• HEMATOLOGIC: No anemia, ease of bleeding, or bruising.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)
• LYMPHATICS: No enlarged nodes. No history of splenectomy.
• ENDOCRINOLOGIC: No polyuria or polydipsia.No sweating, cold, or heat intolerance.

Objective:

Physical exam: N/A

Vital Signs: T 98.1 P-78 R-18 119/74 Ht 5’2” Wt 184lbs BMI = 33.7 kg/m² 

Diagnostic results: Beck Depression Inventory (BDI) is a tool that helps evaluate the severity of depression for undiagnosed or diagnosed individuals. BDI is effective and reliable for evaluating depressive symptoms based on the DSM-5 (Lee & Park, 2022). It would help determine whether the client is depressed and the degree of their depression to aid diagnosis and treatment planning.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Assessment:

Mental Status Examination: Ms J.H. is a 19-year-old Caucasian female who looks her stated age. She is alert and oriented in all spheres. She is well-kept for the occasion and time. She is cooperative and maintains appropriate eye contact. No abnormal motor activity is observed from the patient during the exam. Her thought content and process are logical and goal-oriented. There is no flight of ideas presented by the client. She showed some concentration and attention difficulty during the exam. Her mood is sad, and her affect is congruent with the mood. She sighed most of the time. She denied any visual or auditory hallucinations or delusional thoughts. Her insights and judgment are intact. Her memory is recent and grossly intact. She denies any homicide or suicide ideation. The client is not at risk of harm to herself or others.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Differential Diagnoses:

1. Recurrent Major Depressive Disorder, 296.32 (F33.1). The client presents symptoms that meet the diagnostic criteria for recurrent major depressive Disorder (MDD) with a seasonal pattern, also known as seasonal affective Disorder (SAD). MDD is a mental health condition in which individuals experience depressed mood or loss of pleasure for most of the day, almost daily for two weeks (American Psychiatric Association [APA], 2019). Affected individual experiences loss of pleasure in desirable activities, significant weight gain or loss, hypersomnia/insomnia, psychomotor agitation/retardation,  fatigue, worthlessness, inability to think or concentrate, and recurrent thoughts of death (APA, 2019). To be diagnosed with MDD, a client must present at least five symptoms accompanying depressed mood or loss of pleasure. Recurrent MDD is that which occurs in a cyclic nature.  (Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)
2. Bipolar II Disorder with a current major depressive episode and seasonal pattern, 296.89 (F31.81). The client presents symptoms of bipolar II disorder with current MDD episodes and seasonal patterns. Bipolar II disorder (MDD episodes) is characterized by symptoms similar to those of MDD, such as loss of pleasure in desirable activities, significant weight gain or loss, hypersomnia/insomnia, psychomotor agitation/retardation,  fatigue, worthlessness, inability to think or concentrate, and recurrent thoughts of death (APA, 2019). For seasonality, the individual must experience a regular pattern of at least an episode of depression, hypomania, or mania. A regular temporal relationship between the onset and remission of the episodes and a particular time of the year should be overt and demonstrated in the past two years. (Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)
3. Specific Phobia, natural environment, 300.29 (F40.228). Specific phobias are characterized by anxiety or fear about a specific situation or object (APA, 2019). Affected individuals are often provoked with disproportional anxiety or fear of the situation or object and actively try to avoid the situation or object (APA, 2019). Active avoidance lasts six months or more and is associated with clinical impairment in significant areas of functioning and distress.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Reflection:

The client lost pleasure in spending time with her friends, whom she found “annoying.” She finds her friend dull since they play board games, yet she wants to go outside. The client reports gaining 10 lbs and sleepiness during class hours. She has slept in five of her classes this month alone. She also reports an inability to develop a mock company in her business program or complete projects on time. The client claims she can read a newspaper and immediately forgets the content. Besides, she forgets whatever she learned immediately after leaving the classroom. According to the client’s mother, the client gets moody this time of the year, which suggests a cyclic/seasonal experience.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Recurrent MDD with a seasonal pattern is determined by a regular temporal relationship between the client’s MDD episodes and a particular time of the year (APA, 2019). In this case, the client frets in fall and winter, and the mother knows she gets moody at that tie of the year. A critical aspect of seasonal MDD is the time of onset and remission, and the occurrence of seasonal MDD episodes should outnumber non-seasonal MDD episodes in an individual’s lifetime. This pattern of onset and remission should be consistent for at least two years, which suggests the need to involve the client’s parents in the therapy to provide additional information on the client’s symptoms, particularly its cyclic nature.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

It is difficult to determine whether the seasonal pattern is likely recurrent in MDD or bipolar disorders. However, the seasonal pattern is more common in bipolar II disorder than in bipolar I disorder (APA, 2019). In this case, hypomanic or manic episodes can be linked to the winter season. Ms J.H.’s episodes are more significant depression than manic or hypomanic. Besides, seasonal MDD patterns vary with age, sex, and latitude, age and latitude being a strong predictor of seasonality (Sadock et al., 2015). Younger persons have a higher risk of having depressive episodes during winter, which suggests bipolar II disorder with MDD and seasonal patterns. Although the client meets the diagnostic criterion for bipolar II disorder with current major depressive episodes, there is no indication of current or past manic or hypomanic episodes, which are distinctive features of bipolar disorders.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

The common risk factors for MDD are related to an individual’s temperament, environment, or physiology/genetics. For instance, neuroticism is the joint effect associated with MDD development when faced with stressors (Sadock et al., 2015). Contrarily, adverse experiences and stressful experiences are associated with the development of MDD in an individual. Lastly, individuals are highly likely to develop MDD when a first-degree family member has a history of MDD, and risks increase with early onset.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Regarding Specific Phobia, the client has a significant concern for darkness associated with winter. During this time, she is concerned with boredom and miserableness. This could be described as an associative phobia considering previous experience with winter. The mother herself knows that the client tends to be moody during this time of the year. Moreover, the client knows that winter is miserable, dark, and not fun. However, this diagnosis is refuted since specific Phobia should be experienced for at least six months or more (APA, 2016), yet the client’s experiences that occurred during winter are not extensively disproportional and specific. Social phobias can develop in childhood, while the majority develop past ten years. Situational-specific phobias, such as ones experienced in relation to the natural environment, such as the one experienced by the client, have a later onset. When such phobias persist into adulthood, they are implausible to remit. Temperamental risk factors such as behavioral restriction, as experienced by Ms J.H., are risk factors for developing specific phobias. Moreover, environmental factors such as separation or sexual/physical abuse could also determine the development of a phobia.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

When dealing with adolescents such as this, their desire for independence and privacy raised three ethical and legal issues, i.e., confidentiality, consent, and decision-making capacity. Concerns with consent arise when the mental health practitioner needs to consider whether the client can make independent decisions without parental decisions. In this case, the client can make independent decisions. The practitioner is bound by law to provide all relevant information about the client’s condition (Bipeta, 2019). The issue of confidentiality arises when adolescents keep some information they do not want to be disclosed to others, including parents (Bipeta, 2019). In this case, however, the client’s parents are aware of her situation, and the client would probably not be concerned when they provide additional information to aid in the diagnosis and treatment planning for the client. When it comes to decision-making, the practitioner should evaluate whether the client, in this case, an adolescent, can make decisions related to their healthcare. Practitioners are legally bound to provide the client with information to facilitate informed consent and involve the clients in their care (Sadock et al., 2015). These dilemmas are critical yet fundamental ethical concerns for mental health practitioners handling adolescents.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7^th ed.). American Psychiatric Publishing, Inc.   (Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)

Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian journal of psychological medicine, 41(2), 108-112. https://doi.org/10.4103%2FIJPSYM.IJPSYM_59_19

Eaton, W. W., Bienvenu, O. J., & Miloyan, B. (2018). Specific phobias. The Lancet Psychiatry, 5(8), 678-686. (Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)https://doi.org/10.1016%2FS2215-0366(18)30169-X

Lee, A., & Park, J. (2022). Diagnostic test accuracy of the beck depression inventory for detecting major depression in adolescents: A systematic review and meta-analysis. Clinical Nursing Research, 31(8), 1481-1490. https://doi.org/10.1177/10547738211065105

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.(Comprehensive Soap Note on Assessing And Diagnosing Patients With Mood Disorders-Nursing Paper Example)