Clinical SOAP Note Comprehensive Nursing Paper Example

Clinical SOAP Note Comprehensive Nursing Paper Example

Criteria Clinical Notes

Informed Consent: Informed consent was given to the patient about the psychiatric interview process and psychiatric/psychotherapy treatment, and verbal and written consent was obtained. The patient can respond and appears to understand the risk and benefits of the treatment plan. (Clinical SOAP Note Comprehensive Nursing Paper Example)

Subjective Verify Patient Name: Lewis Blakes DOB: 21/09/1996 Demographic: The patient is a 25-year-old male accompanied to the facility by his parents for a follow-up clinic. The patient presents for treatment for major depressive disorder. The patient completed his studies in mid-last year, but he has not managed to secure a job. He lives with his parents as he cannot sustain himself due to financial reasons. Gender Identifier Note: Male CC: “Why is life so unfair?” HPI: The patient has been shifting from low to high moods recently. He started developing depressive symptoms four months ago after getting his job applications rejected by different organizations. His parents add that the antidepressants he was given in the last clinical visit have not been effective in improving the symptoms. However, his suicidal thoughts have decreased with time. Pertinent history in the record and from the patient: yes Previous medication trials: unknown at this time. Safety concerns: History of Violence to Self: one suicidal attempt History of Violence to Others: NA Auditory Hallucinations: denies. Visual Hallucinations: denies Mental health treatment history discussed: History of outpatient treatment: unknown at this time Previous psychiatric hospitalizations: Unknown at this time Prior substance abuse treatment: Trauma history: The patient denies having trauma. Substance Use: The client denies having any dependence on substances (Clinical SOAP Note Comprehensive Nursing Paper Example)

Current Medications: Antidepressants (Contraceptives): N/A Supplements: N/A Past Psych Med Trials: unknown at this time Family Medical Hx: Unknown Family Psychiatric Hx: Mother, has an anxiety disorder. Social History: Occupational History: Not employed Military service History Denies previous military hx. Education history: Completed his studies mid-last year. Developmental History: no significant details were reported. (Childhood History include in utero if available) Legal History: no reported/known legal issues, no reported/known conservator or guardian. Spiritual/Cultural Considerations: none reported. ROS: Constitutional: Reports weight loss. Eyes: No report of acute vision changes or eye pain. ENT: No report of hearing changes(Clinical SOAP Note Comprehensive Nursing Paper Example)

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: Reports 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: No report of significant issues. (Clinical SOAP Note Comprehensive Nursing Paper Example)

Objective Vital Signs: Height 5’12”, weight 115, BP 128/24, Pulse rate 87, Temperature 98.2F Labs: No blood work currently available. Physical Exam: MSE: The patient mood is depressive. Patient avoidant of eye contact. The patient keeps rubbing his arms together The patient has regular motor activity The patient is well-kempt. Denies having a hallucination. (Clinical SOAP Note Comprehensive Nursing Paper Example)

Assessment DSM5 Diagnosis: with ICD-10 codes

The patient has depression Patient meets DSM-V criteria for: · Anxiety disorder, unspecified, F41.9 · Major depressive disorder, recurrent, F33.1 · Panic Disorder, F41.0 · Generalized anxiety disorder, F41.1 Differential Diagnoses Generalized anxiety disorder, F41.1 Major depressive disorder F33.1 Major depressive disorder F32.3- Confirmed The patient suffers from a major depressive disorder caused by changes in his life in that he has not found any job despite several applications to different organizations. He feels the pressure to be independent like most of his peers, move from his parents’ house and pursue his electrical engineering career. He feels that life is unfair because his hard work in school has not borne any fruits so far. His social life has also changed, as he has lost contact with his close friends and mainly spends most of his time by himself and his dog. From these changes, 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 basketball which he previously found interesting, insomnia, and feeling like everything in the world is against him, confirmed the presence of major depressive disorder (Köhler‐Forsberg et al., 2019). (Clinical SOAP Note Comprehensive Nursing Paper Example) The depression needs to be addressed in urgency to avoid recurrent suicidal ideation. Some effective treatment options for major depressive disorder are antidepressants and cognitive behavioral therapy. The patient ruled out the cognitive behavioral therapy stating that he found it emotionally uncomfortable and increased his anxiety. Additionally, he ruled out Zoloft, his previous medication claiming that it was not very effective in improving his condition and increased insomnia, which made him have multiple thoughts at night while he needed a rest. In this case, the treatment options available for the patient are selective serotonin reuptake inhibitors (SSRIs), including Celexa, Lexapro, Prozac, Bupropion, and Paxil (Cohen & DeRubeis, 2018). The most appropriate treatment for the patient is Bupropion, 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. As a result, the patient’s depressive symptoms will reduce, improving his quality of life. Additionally, the patient will be more willing to follow up with the medication as it balances out the neurotransmitter imbalance that causes depression and does not cause insomnia (Cohen & DeRubeis, 2018). Generalized anxiety disorder, F41.1 The patient has constant, excessive, and uncontrollable worry about whether his condition will improve. His parents add that despite giving him alternative jobs he can do in the meantime, the patient is just interested in engineering and feels that is his passion and keeps. (Clinical SOAP Note Comprehensive Nursing Paper Example)

sending applications, where he keeps being rejected. Using the DSM-5 criteria for generalized anxiety disorder, the patient has constant, excessive, and uncontrollable worry about whether his condition will improve, confirming the disease. He also has difficulty sleeping and concentrating chronic fatigue and finds it challenging to handle uncertain situations. The treatment options are anti-anxiety medication for the short term to address muscle tensions. They include Xanan, Ativan, and Clonazepam. However, they should not be taken for an extended period, increasing dependency (DeMartini et al., 2019). On the other hand, antidepressants including Lexapro, Paxil, Buspar, and Pristiq can help address anxiety symptoms in the long run. In this case, I would recommend Ativan to help manage the symptoms and does not cause insomnia (Strawn et al., 2018). Treatment Goals Major depressive disorder- to help avoid another onset of suicidal thoughts. General anxiety disorder- to help improve coping with 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. (Clinical SOAP Note Comprehensive Nursing Paper Example)

Plan

(Note some items

may only be

applicable in the Inpatient: inpatient environment) Safety Risk/Plan: The patient denies abnormal perceptions and does not appear to be responding to internal stimuli. Pharmacologic interventions: including dosage, route, and frequency and non-pharmacologic: Pharmacological interventions · Pharmacological · Medications: Bupropion 150 mg to be taken in the morning for major depression disorder. Ativan 3mg per day to be taken three times a day for generalized anxiety disorder. 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). In addition, the patient will be educated on the adverse effects of substance abuse and how to live a sober life. Referrals: N/A. (Clinical SOAP Note Comprehensive Nursing Paper Example)

Follow-up TBD upon closer to discharge The patient will follow up every three weeks to check his progress. This will help perform physical and lab tests to address any abnormal findings on time. Date: 3/24/2022 Time: 1140 (Clinical SOAP Note Comprehensive Nursing Paper Example)

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 (Clinical SOAP Note Comprehensive Nursing Paper Example)

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine, 170(7), ITC49-ITC64. (Clinical SOAP Note Comprehensive Nursing Paper Example)

Köhler‐Forsberg, O., N. Lydholm, C., Hjorthøj, C., Nordentoft, M., Mors, O., & Benros, M. E. (2019). Efficacy of anti‐inflammatory treatment on major depressive disorder or depressive symptoms: meta‐analysis of clinical trials. Acta Psychiatrica Scandinavica, 139(5), 404-419. (Clinical SOAP Note Comprehensive Nursing Paper Example)

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057-1070 (Clinical SOAP Note Comprehensive Nursing Paper Example)

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