Clinical SOAP Note

Criteria Clinical Notes Comprehensive Nursing Essay Example

Informed

Consent Informed consent was granted by the patient himself about the psychiatric interview process and subsequent psychiatric and psychotherapy treatment. Both oral and verbal consent was secured with DH demonstrating the ability and capacity to respond and appears to fathom the risks, and benefits and, wherever necessary, promise to review additional consent in the treatment plan discussion. (Criteria Clinical Notes Comprehensive Nursing Essay Example)

Subjective CC: “Of late, I have been experiencing intense fear, always being on guard for danger, and trouble concentrating.” HPI: A 32 yo male of African American descent presents to the clinic complaining of getting startled or frightened, accompanied by insomnia and difficulties concentrating. He states that he works as stevedore, is married to his wife of six years, and has a 4-year-old girl. He denies taking alcohol, has no known allergies, and is currently on medication chlorthalidone 25mg/daily PO for high blood pressure as prescribed by his GP. DH’s mother has a history of hypertension, a major compulsive disorder. He has been back in New Orleans over the last 12 months after serving an 18- month military tour in Afghanistan before the US withdrew its troops. He reports having taken part in frontline combat and experiencing nightmares and intense anxiety with his physician for about seven months. He also admits to angry outbursts accompanied by overwhelming guilt and the urge to engage in unprotected sex or exceed the speed limit while driving. The GP referred him for psychiatric evaluation as the heightened anxiety, sleeplessness, nightmares, and fear triggered by loud noise did not abate. Past Medical Hx: Medical history: Has been diagnosed with hypertension which he effectively manages using Chlothalidone. Surgical history: Negative. Past Psychiatric Hx: Previous psychiatric diagnoses:(Criteria Clinical Notes Comprehensive Nursing Essay Example)

HPI

Denies past psychiatric history, although the father is currently struggling with alcohol addiction while the mother has MDD and hypertension. Patient reports drinking 2-3 bottles of beer every night as it helps sleep and reduces nightmares. These symptoms started about seven months ago but have increased in intensity and frequency, especially in the last five weeks. Associated symptoms include tremors, breathlessness, and nightmares. He reports that traffic exacerbates these symptoms, but alcohol relieves the same. Current Medications: Chlothalidone 25mg/day PO. (Contraceptives): N/A Supplements: None Previous medication trials: Unknown. Allergies: NKDA Mental Health Treatment History: The patient had been treated for acute stress disorder through cognitive behavior therapy (CBT) which proved ineffective after the patient dropped halfway through the slated 990-day therapy session. He failed to attend the bi-weekly sessions opting to use OTC antidepressants. The patient denies any history of treatment for substance abuse.(Criteria Clinical Notes Comprehensive Nursing Essay Example) Trauma history: The client reports escaping unhurt when their armored vehicle stepped on a land mine, and 5 of his colleagues died and sustained lifelong disabilities. Also, he reasons the impact was in his mind, as evidenced by the nightmares, tremors, and other unpleasant symptoms he relives every day and night. Substance Use: Admits taking 2- 3 bottles of beer every day to steel his nerves. Past Psych Med Trials: unknown at this time Family Medical Hx: Mother aged 61 years living with MDD, and hypertension, a father aged 65 years struggling with alcohol addiction. Family Psychiatric Hx: His only sister committed suicide by jumping off a bridge after she found hr then-boyfriend was cheating on him. Mother has MDD Birth and Development History: He achieved all developmental milestones as a normal child with no serious illnesses until he returned from the war front in Afghanistan in 2021. ROS: Constitutional: Negative for weight loss or fevers Eyes: Negative for acute vision changes, eye pain, ENT: Negative for hearing changes.no, nose bleeding, and easy swallowing of food.(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Cardiac: Positive for chest pain, palpitations dyspnea, and edema. Respiratory: Reports dyspnea, no cough or wheeze. GI: Negative for reflux because the abdomen is soft and non-tender. Normoactive bowel sounds. GU: Negative for flank pain, no dysuria. Musculoskeletal: Negative for joint pain, positive for ankle swelling. Skin: Negative for rash, lesion, or abrasions. Neurologic: Negative for seizures, blackout, numbness, or focal weakness. Endocrine: Negative for polydipsia and polyuria. Hematologic: Negative for splenectomy, denies blood clots or easy bleeding Allergy: Denies hives and allergic reactions.(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Objective Vital Signs: BP 157/96, HR 90, Temp 97.5, RR 18, O2 97% Ht 5’7” Wt 155lbs, BMI 23 Lab tests results CBC: currently unavailable. No other labs drawn Physical Exam: None Contributory MSE: Appearance: appropriately dressed for the occasion and appears the stated age Behavior: Composed, focused with intermittent eye contact but the inability to engage with the provider Attitude: Cooperative and appears in no acute distress. Level of consciousness: increased vigilance Awake, Alert Orientation: A*4 Speech and Language: clear and coherent Mood: describes it as angry and tense Affect: Mood congruent, moderately restricted Thought process/form: Distorted sense of self-blame Thought content: Depressed, suicidal ideations Suicidality and homicidally: Has history of suicide attempts denies homicidal thoughts Insight and judgement: Insight considered to be good, judgement moderate Attention span: Easily startled/ disrupted has difficulties concentrating Memory: Both recent and remote deemed moderately impaired as evidenced by perceptual disturbances like flashbacks and dissociation Intellectual functionality: Intellectually capable Relevant Screening Tools Clinician-Administered PTSD Scale(CAPS-5 Scale) with a severity rating of moderate/threshold(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Assessment

Informed Consent Ability DSM5 Diagnosis: with ICD-10 codes Diagnosis 1. F43.1 Post-Traumatic Stress disorder 2. F60.5 Obsessive-Compulsive personality disorder 3. F41.1 Generalized anxiety Disorder Differential Diagnoses: 1. F43.1 Post-traumatic Stress disorder(Confirmed) PTSD is a clinical phenomenon found in clients who have been exposed to major stressors in life, like wars or natural disasters. DH presents with all three classic clinical manifestations of PTSD. Miao et al. (2018) opine that individuals suffering from PTSD display symptoms of hyperarousal, avoidance, and reliving their recent combat experiences and have triggers like traffic. The patient further reported withdrawing from activities and had negative alternations in cognition and arousal. Additionally, CAPS-5 is a 30-item questionnaire where the patient is required to endorse up to three traumatic events during the interview. After scoring the CAPS-5 corresponding to the patients’ experiences over the last four weeks, a severity score of severe or markedly elevated was determined.(Criteria Clinical Notes Comprehensive Nursing Essay Example) This is because the patient has the classic symptoms of PTSD a minimum frequency of 2 times every week with a minimum intensity of pre pronounced. These manifestations and the PTSD mnemonic of R3D2 for intrusion symptoms, AFRAID for avoidance symptoms, and SCARE for arousal symptoms were used to confirm a PTSD diagnosis (Kadiyala, 2020). 2. F60.5 Obsessive Compulsive personality Disorder (Refuted) Obsessive-compulsive personality disorder and PTSD have overlapping symptoms like intrusive and distressing clinical symptoms. Both fear and anxiety are present in each of the diseases. However, OCD can happen after a precipitating event, unlike PTSD whose hallmark is experiencing severe trauma. With the patient reliving the recurrent memories of the traumatic experience (Morina et al, 2016). These amongst other symptoms were used to rule out OCD as the likely Diagnosis. 3. F41.1 Generalized anxiety Disorder (Refuted) The patient does not have GAD because he continues to experience the symptoms of anxiety after several months have passed since the traumatic events happened. It is

important to note that the patient remains hypervigilant and has flashbacks and dreams of the traumatic events (Przeworski, & Dunbeck, 2016). However, the patient’s hypertension is likely to intensify the bodily sensations of heart palpitations, sweating, and increased blood pressure as the patient becomes anxious as he relieves the combat experiences. Treatment goals: There are several treatment goals after confirming a diagnosis of PTSD in the patient. (Criteria Clinical Notes Comprehensive Nursing Essay Example)These are; Ø to ease the PTSD symptoms. Ø Reduce the frequency of these symptoms Ø Make the symptoms less intrusive in the patient’s life Ø Teach the patient how to manage the symptoms when they occur Ø Reinstate a positive sense of self and self-esteem for the patient. Informed Consent Ability: The patient has/demonstrated the capacity to respond to psychiatric pharmacological and psychotherapy interventions and appears to understand the need for medications/psychotherapy and is ready and willing to adhere to the recommended treatment and care plan.

Plan

Pharmacological Interventions Because the patient has a history of noncompliance in CBT sessions, pharmacological interventions should be introduced. Zoloft 50 mg daily PO is initiated. According to Huang et al. (2020), studies have found that sertraline is more effective in lowering the severity of PTSD on a clinician-assessed scale. (Criteria Clinical Notes Comprehensive Nursing Essay Example)At the same time, using this medication would have added benefits of helping manage the patient’s hypertension as it effectively removed or decreased symptoms of paroxysm hypertension in most of the most where it was used. The drug’s mechanism of action is thought to be associated with inhibiting CNS neuronal uptake of serotonin. However, the patient should be taught how to cope with the medication’s side effects like nausea and appetite loss, among others. Non-Pharmacological Interventions Patient education on non-pharmacological intervention like counseling using telehealth services like zoom counseling sessions since the patient complained of long distances and time wasted while traveling to attend the CBT sessions. (Sttewart et al., 2017).(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Complementary and alternative therapies like meditation, yoga and deep breathing exercises will also be incorporated. Awareness should focus on why he should adhere to the psychoactive\drugs and those to help manage his hypertension. The role of physical exercise and a diet with less salt intake is also required in this patient. Referral: The patient is to be referred to a Psychotherapist for CBT. Follow up: Follow up in a clinic in 8 weeks or earlier if the symptoms worsen despite the increased dosage.(Criteria Clinical Notes Comprehensive Nursing Essay Example)

References

Huang, Z. D., Zhao, Y. F., Li, S., Gu, H. Y., Lin, L. L., Yang, Z. Y., … & Luo, J. (2020). Comparative efficacy and acceptability of pharmaceutical management for adults with posttraumatic stress disorder: a systematic review and meta-analysis. Frontiers in pharmacology, 11, 559.(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Kadiyala, P. K. (2020). Mnemonics for diagnostic criteria of DSM V mental disorders: a scoping review. General psychiatry, 33(3).(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Morina, N., Sulaj, V., Schnyder, U., Klaghofer, R., Müller, J., Martin-Sölch, C., & Rufer, M. (2016). Obsessive-compulsive and posttraumatic stress symptoms among civilian survivors of war. BMC psychiatry, 16(1), 1-8.(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Murphy, D., Ross, J., Ashwick, R., Armour, C., & Busuttil, W. (2017). Exploring optimum cut-off scores to screen for probable posttraumatic stress disorder within a sample of UK treatment-seeking veterans. European journal of psychotraumatology, 8(1), 1398001.(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Przeworski, A., & Dunbeck, K. (2016). Generalized anxiety disorder: How it compares to PTSD. Comprehensitve Guid. to Post-Traumatic Stress Disoder.(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Stewart, R. W., Orengo-Aguayo, R. E., Cohen, J. A., Mannarino, A. P., & de Arellano, M. A. (2017). A pilot study of trauma-focused cognitive–behavioral therapy delivered via telehealth technology. Child maltreatment, 22(4), 324-333.(Criteria Clinical Notes Comprehensive Nursing Essay Example)

Vaclavik, J., Krenkova, A., Kocianova, E., Vaclavik, T., & Kamasova, M. (2018). Effect of sertraline in paroxysmal hypertension. Biomedical Papers, 162(2), 116-120(Criteria Clinical Notes Comprehensive Nursing Essay Example)

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