Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example

Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example

Informed Consent The patient gave informed consent on the psychiatric interview process and the subsequent psychiatric/ psychotherapy treatment. This means both verbal and written consent were secured since the patient demonstrated both ability and capacity to respond and appears to fathom the risks, benefits, and promises to review additional consent at any stage of the treatment plan discussions. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Subjective CC: “I just feel depressed and it’s all my fault”. HPI: CF is a 51 y/o African American female single lady with a history of depression who presents to the clinic c/o increased anxiety. She admits anxiety has been a chronic problem that has steadily increased in the past few weeks accompanied by lack of sleep, body tension and shaking. She reports just feeling depressed with symptoms severity being enough to interfere with activities considered instrumental for daily living. She reports she is currently on medication therapy but feels the symptoms have worsened despite her taking Lexapro 10 PO once daily. She’s positive to many recent life stressors like having a benign tumor on her left breast with subsequent hospitalization and her dear mother is on her death bed. Two months ago, she lost her only sister and admits she is still in the grieving process. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example) She reports her steady partner was supportive until eight months ago when he fell for a 30 y/o female workmate of CF leading to their eventual break pushes reports to having consulted a psychiatrist for anxiety/depression in the past. She denies smoking, and claims to be a tee-totaller. Past Medical Hx: Medical history: Patient admits she has hypertension. Acute illnesses include a loss of a finger after she accidently cut it off while she was chopping a piece of sugarcane at age 33. Reports a lumpectomy but denies other surgical history. Surgical history: Lumpectomy at age 51 yrs. Past Psychiatric Hx: Previous psychiatric diagnoses: diagnosis of, depression, and anxiety. Describes worsening course of illness. Current Medications: Lexapro 10mg PO once daily (Contraceptives): None Supplements: Calcium 500mg and Vitamin B6 500mg Previous medication trials: Unknown. Allergies: NKDA Therapy History:(Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

HPI

Anxiety: CF confirms significant social anxiety and reported this began in high school. Reported that she experiences challenge leaving the house and is engulfed with intense fear accompanied by shaking and fast breathing. She has taken Benadryl an OTC medication and found it to be fast acting and convenient though she can’t recall the dosage. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example) Depression: Patient reports feeling depressed since last year April when a string of misfortunes and tragedies struck her close family members and relatives. The mood swings have increased in intensity in the last two weeks. She reports inability to sleep in a bed she had shared with her late sister and gets three to four hours of sleep. Confirms having sought treatment for depression and admits having experienced other episodes prior to this occurrence. Mental health treatment history discussed: History of outpatient treatment: three-month CBT course for depression Previous psychiatric hospitalizations: Unknown at this time Prior substance abuse treatment: Negative Trauma history: Client reports no forms of childhood abuse or even as an adult. Substance Use: Negative- Patient claims to be a tee–totaller Past Psych Med Trials: unknown at this time Family Medical Hx: Mother at 71 years diagnosed with advanced stage breast cancer, father died at age 63 years due to complications arising from T2DM. Family Psychiatric Hx: Noncontributory except for a maternal uncle who committed suicide by taking drug overdose. Birth and Development History: Reports no issues with developmental milestones as all were attained with no challenges.(Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example) ROS: Constitutional: Healthy looking AA female, alert, afebrile and in mild acute distress Eyes: Negative for eye pain, no discharge, and no sight changes. ENT: Negative for hearing changes.no running nose, bleeding, no difficulties in swallowing food. Cardiac: Denies chest pain, edema or orthopnea. Respiratory: Denies shortness of breath, cough or wheeze. GI: Negative abdominal pain abdomen is soft, non- tender. Normoactive bowel sounds. GU: Negative for excessive thirst and frequent urination. Musculoskeletal: Negative for joint pain or swelling. Skin: Negative for rash, lesion, abrasions. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Neurologic: Denies seizures, blackout, numbness or focal weakness. Endocrine: Negative for both polyuria and polydipsia. Hematologic: Negative for blood clots or easy bleeding or splenectomy Allergy: Negative for hives or allergic reaction. Reproductive: LMP 10 days ago Cycle length and frequency 3/28 light bleeding IMB –Absent PCB-Absent Age of Menarche/Menopause- 12 and 48 years respectively Miscarriages G 3 P 2A 1 L 1 : (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Objective Vital Signs: BP 161/97, HR 90, Temp 97.5, RR 19, O2 97% Lab tests results CBC: currently unavailable. TSH- 0.9- 3.9 mU/L BUN levels 9-20 mg/dL, serum creatinine levels 0.61- 1.03mg/dL Physical Exam: None Contributory. MSE: Appearance: Well groomed, dressed for the occasion and appears the stated age Behavior: Composed , focused with intermittent eye contact Attitude: Cooperative, easy to establish a discussion Level of consciousness: Awake, Alert Orientation: A*4 Speech and Language: Soft clear, coherent Mood : context appropriate Affect: Mood congruent, moderately restricted Thought process/form: organized, goal directed, logical 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: adequate to the needs of an outpatient program, age appropriate Memory: Both recent and remote deemed intact Intellectual functionality: Intellectually capable Relevant Screening Tools GAD-7: Was used to screen for generalized anxiety and her score was 13 –moderate anxiety Patient Health Questionnaire (PHD-9) -15 moderately severe depression Columbia Suicide Severity Rating Scale (C- SSRS) moderate risk (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Assessment DSM5 Diagnosis: with ICD-10 codes Diagnosis 1. F33.1 Major Depressive Disorder 2. F41.1 Generalized Anxiety Disorder 3. E05 Hyperthyroidism 4. G 20 Parkinson disease Differential Diagnoses: 1. F33.1 Major Depressive Disorder( MDD)-confirmed Bains & Abdijadid (2021) note that individuals who present with sleep disturbances, report a significant loss of interest in activities that used to give them pleasure and are currently guilt ridden for real or imaged causes and feeling worthless are likely candidates for MDD diagnosis. Using the Mnemonic SIG-E-CAPS the MDD diagnosis was confirmed because in addition to sleeplessness, interest loss in earlier pleasurable activities and guilt- complex, the patient reports lack of energy manifesting as fatigue,. While her cognition is not significantly affected excessive appetite, and psychomotor agitation through anxiety and being haunted with suicidal thoughts.(Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example) Most importantly these symptoms have lasted for more than six months increasing in intensity in the last seven weeks. 2. F41.1 Generalized Anxiety Disorder (Confirmed) Mental healthcare providers are reminded that GAD and MDD can co-occur and even have some overlapping symptoms like irritability, insomnia and restlessness. A patient with GAD constantly worries and has difficulties controlling the worry (Stein et al, 2021). It was confirmed as a co-occurring condition t because the patient in context has mood swings, displays a flat affect with marked appetite changes as evidenced in excessive eating in addition to palpitations and fast breathing amongst other signs and symptoms of GAD. 3. E05 Hyperthyroidism(refuted) Hyperthyroidism is a condition that could trigger clinical manifestations that are similar to those MDD. Its cause though is excessive concentration of thyroid hormones (Kravets, 2016). It was ruled out because the lab results ordered indicated normal TSH levels. The recommended treatment management care plan for this patient should factor in the management of existing comorbidities like hypertension. Hydrochlorothiazide 25mg PO once daily is prescribed (Akbari & Khorasani-Zadeh, 2021). In case of a missed dose, the patient should take it soonest possible but if the next dose is almost due, the patient should skip the missed dose and go back to her regular dosing schedule. She should not take a double dose. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Informed Consent Ability The plan to use will also incorporate teaching/ patient education on how to overcome some of the life challenges through adjunct psycho education for the patient and key family caregivers. She also be discouraged on the use of OTC and receive worry management skills.CF should also be encouraged to engage in physical activity. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example) Treatment goals: a. To achieve remission or give the patient complete relief from all symptoms. b. To help restore healthy functioning of the brain. c. To assist the patient, lead a healthy quality of life Informed Consent Ability: Patient hasability/capacity appears to respond to psychiatric pharmacological and psychotherapy interventions and appears to understand the need for medications/psychotherapy and ready and willing to adhere to the recommended treatment and care plan. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Plan

Pharmacological Interventions The escitalopram dosage should be increased to 20mg /day to determine the medication’s effectiveness. (Jiang et al, 2016). According to this researcher, the efficacy of Lexapro medication in treating MDD comorbid with GAD has been determined in short term studies. The drug works by increasing intrasynaptic levels of neurotransmitters serotonin. It does this action by blocking the reuptake of the neurotransmitter into the presynaptic neuron. The patient should be made of Escitalopram 20mg like headache, nausea, dry mouth, and constipation. Other side effects are like weight gain, flatulence, menstrual disorder and decreased libido. The prescriber should closely monitor the patient for worsening condition, increased suicidality. The provider should also monitor serum magnesium and correct hypokalemia and other electrolyte imbalances. The drug is contraindicated in patients diagnosed with syndrome of inappropriate ADH, low magnesium, sodium, and potassium levels in the blood. The patient should also continue taking medications that help her control her hypertension. Non pharmacological interventions will include using relaxation techniques to lower stress l Referral: The patient is to be referred to a Psychotherapist for CBT. Follow up: Follow up in clinic in 6 weeks, or earlier if the symptoms get worse despite the increased dosage. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

References

Akbari, P., & Khorasani-Zadeh, A. (2021). Thiazide diuretics. StatPearls [Internet]. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Bains, N., & Abdijadid, S. (2021). Major depressive disorder. StatPearls [Internet]. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Cosci, F., & Fava, G. A. (2021). When anxiety and depression coexist: the role of differential diagnosis using clinimetric criteria. Psychotherapy and psychosomatics, 90(5), 308-317. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Jiang, K., Li, L., Wang, X., Fang, M., Shi, J., Cao, Q., … & Hu, C. (2017). Efficacy and tolerability of escitalopram in treatment of major depressive disorder with anxiety symptoms: a 24-week, open-label, prospective study in Chinese population. Neuropsychiatric Disease and Treatment, 13, 515. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Kravets, I. (2016). Hyperthyroidism: diagnosis and treatment. American family physician, 93(5), 363-370.

Stein, D. J., Kazdin, A. E., Ruscio, A. M., Chiu, W. T., Sampson, N. A., Ziobrowski, H. N., … & Kessler, R. C. (2021). Perceived helpfulness of treatment for generalized anxiety disorder: a World Mental Health Surveys report. BMC psychiatry, 21(1), 1-14. (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

Van Krugten, F. C., Kaddouri, M., Goorden, M., Van Balkom, A. J., Bockting, C. L., Peeters, F. P., … & Decision Tool Unipolar Depression (DTUD) Consortium. (2017). Indicators of patients with major depressive disorder in need of highly specialized care: A systematic review. PLoS One, 12(2), e0171659 (Social Anxiety Clinical SOAP Note Comprehensive Nursing Paper Example)

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