Focused SOAP Note and Patient Case Presentation
· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
· Objective: What observations did you make during the psychiatric assessment?
· Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
· Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
· In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
· Reflection notes: What would you do differently with this patient if you could conduct the session over? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
CASE STUDY
Chief Complaint: Patient stated “ I came in because I was depressed and having suicidal thoughts.”
HISTORY OF PRESENT ILLNESS:
Y.R is a 18-year old African American female who came to ED due to severe depression, suicidal ideations, non compliance with medications, severe anxiety, racing thoughts, and mood swings, marijuana use, commanding auditory hallucinations, and difficulty sleeping at night. During interview patient started “I feel depressed, anxious, I have trouble sleeping at night, I stopped taking my medication in over a year because it was making me feel worse. I used to take Zoloft and ability. I hear voices telling me bad and negative things like give up and hurt myself. I have thoughts of wanting to hurt myself.” Patient denies homicidal ideations. The patient at this time is danger to self and others. The plan is to start medications, encourage patient to attend groups, and social service to follow up with placement and appointments (including PHP and drug rehab referral.)
PAST PSYCHIATRIC HISTORY
Patient denies and past inpatient psychiatric hospitalizations, reports seeing psychiatrist Dr. H., outpatient clinic at Howard Brown. Last visit was in May 2021. Patient in the past was prescribed Zoloft and Ability but claims that both medications made her symptoms worse and stopped taking both medications. She has been noncompliant with medications over year. Patient wishes to try different psychotropic medications. Patients received prescriptions for Abilify 2mg on 4/7/2022 as per medication reconciliation external profile but never took the medication.
Patient reports past suicidal attempt, twice in her lifetime, first attempt was when patient was 13 years old via biting her self in her arm and lip. She also attempted this same behavior again at 16 years old. (2ndattempt). Patient denies any past homicidal attempts.
Patient reports being diagnosed as major depression, ADHD, and PTSD. Patient reports being sexually abused when she was a teenager.
PAST MEDICAL HISTORY:
Patient reports obesity only.
FAMILY HISTORY:
Patient reports her mother has bipolar disorder. Also, her grandmother has bipolar disorder, major depression and OCD.
PERSONAL/SOCIAL HISTORY:
SOCIAL HISTORY: Patient reports living with her partner, one daughter who is two months old and living with partner. Currently unemployed and denies receiving any monthly financial benefits. She is positive for marijuana use as per UDS. HCG negative. Denies any past legal history. Denies owning any firearms.
LABS:
Positive Marijuana
Negative HCG
Glucose 143
Sodium 135
TREATMENT/PLAN
1. Based on the patient’s presenting symptoms and past history, the diagnosis will be bipolar disordered Mixed Episode with psychotic features. The patient noted to be disorganized, hypomanic, responding to internal stimuli, guarded, anxious, isolative, and withdrawn to self. The patient reports severe depression, difficulty sleeping at night, severe mood swings, racing thoughts, and anxiety during the day, marijuana use, noncompliance with medications in over a year, commanding auditory hallucinations, and suicidal ideations. The patient is a danger to self and others. Requires inpatient psychiatrist hospitalization.
2. Based on the past hospitalizations and the symptoms presented by the patient, the plan is to start Trileptal 300 mg PO BID and Seroquel 100 mg PO at bedtime. Medication education provided to the patient including side effects and adverse drug reactions. After education, patient agreed to start these medications. Substance abuse education provided as well.
3. The patient was encouraged to attend group therapy to improve insight, judgment, and compliance.
4. Social service to follow up with appropriate placement and appointments (including PHP and drug rehab referral).
3 DIAGNOSIS (NOTE: USE DSM-5 TO WRITE ABOUT THE BELOW DIAGOSIS AND RELATE IT TO PATIENT’S PROBLEM BASED ON HER HISTORY.
· Bipolar Disorder Mixed Episode with Psychotic Features
· Personality Development Disorder
· Substance Abuse