SOAP 3 Response

The required discussion response(s) to student or faculty for each weekly question(s) is (are) completed by Saturday at 11:59 PM ET for each electronic week. These postings are on different days of the week than the initial post(s). Minimum of 300 words.

STUDENT’S SOAP

Name of Patient: PF

Date of Service: 10/7/26

Session Type:/Intake via telehealth

Time: 10:30-12:30

Chief Complaint: “I’m feeling chronic emptiness, I have a fear of abandonment and feel unstable in relationships and have unstable moods.”

Subjective:

PF is a 48-year-old Hispanic female who presents with a history of anxiety and depression who presents for psychiatric evaluation with concerns about emotional dysregulation and interpersonal difficulties. She reports struggling with self-worth and experiences chronic emptiness most days. The patient describes episodes of impulsivity, particularly during periods of stress, where she may send mean texts that she later regrets within an hour or the next day, creating a "domino effect" where she gets into trouble with everyone. When stressed, she copes by isolating herself or "hiding out," and sometimes drinks a bottle of wine to relax or "feel like a normal person." She experiences suspiciousness and fear that others at work will leave or betray her, often having "weird feelings" about people and feeling she needs to be careful around certain individuals. The patient reports that her emotions can be intense and difficult to control, with depression sometimes serving as a trigger for emotional distress. She describes a history of childhood trauma and fear of abandonment or rejection in relationships. Her past relationships have been unstable and intense, with a tendency to view people as either good or bad depending on the situation, especially when things are not going her way. The patient has been on duloxetine for approximately 5 years, previously at 80mg, then 60mg, and reports feeling like she has plateaued on the medication. She sees a psychiatrist monthly who primarily focuses on anxiety and depression management with prescription refills, without much discussion of other symptoms. Her depression appears to be mostly controlled with some residual symptoms, and her anxiety is also largely managed. Regarding sleep, she previously had significant trouble sleeping but reports improvement over the past 1-2 months, sleeping well on her own 3-4 days per week without taking anything. She does wake up several times during the night and takes time to fall back asleep. She denies frequent nightmares.

OLDCARTS Assessment

Onset: Feeling of abandonment started as a child and has progressed

Location: Patient has thoughts of not having self-worth and emptiness.

Duration: Patient states most days she has these feelings.

Character: Patient reports episodes of impulsivity.

Aggravating Factors: Patient contributes these behaviors when she is feeling stressed and will send mean text to people. She also feels this ill behavior when she feels that co-workers will leave or betray her.

Relieving factors: Patient hides out or drinks a bottle of wine.

Timing: These behaviors can occur at any time of the day.

Pertinent Negatives

P.F. denies any suicidal, homicidal, or violent thoughts.

P.F. denies history of self-harm

Review of Systems

No physical exam completed, this is a tele psych visit. The patient appears to be in good physical health

Medical History: None

  Surgical History: None

  Psychiatric History:

Anxiety, diagnosed and treated for approximately 5 years

Depression, diagnosed and treated for approximately 5 years

Childhood trauma

Hospitalizations none

Psychotherapy, sees a physiatrist on monthly basis

  Medications and Supplements

Duloxetine, by mouth, currently at a lower dose, previously at 80 mg then 60 mg; has been on the medication for approximately 5 years; patient reports feeling plateaued on this medication.

Allergies

No known allergies

Social History:

Substance Use: Reports drinking a bottle of wine at times as a coping mechanism during periods of stress.

Occupation: Currently employed; references coworkers in the workplace.

Relationships: History of unstable and intense past relationships; describes difficulty with trust and fear of abandonment in relationships.

Trauma History: Childhood trauma reported.

Coping Mechanisms: P.F. isolates herself and hide out during stressful periods; engages in impulsive behaviors such as sending mean text messages when upset, followed by regret; reports chronic feelings of emptiness and low self-worth.

I would have asked about her family history of mental illness and what is her occupation. I would have asked her how many milliliters is each bottle of wine and how many days of week does she drinks.

Assets and Stressors

Assets: P.F. has stable employment

Stressors: P.F. thinks her co-workers will abandon her, she also struggles with self-worth.

Objective Data:

P.F. have no apparent serious mental status abnormalities. She is normal in appearance with age-appropriate dress and grooming and she appears to be her stated age. Reports mood swings chronic emptiness "most days." Sad affect. Her speech is normal in rate, volume, and articulation and her language skills are intact.  Her thought content includes being suspicious about coworkers, stating "I always have this like weird feeling like I just like oh like... Like somebody's going to happen or I can tell they're this kind of person, so I need to be careful. She convincingly denies suicidal and self-injurious ideas or intentions. Homicidal or assaultive ideas or intentions are also denied. Hallucinations and delusions are denied and her behavior is generally appropriate. Associations are intact, thinking is basically logical and thought content is appropriate. There are no signs of cognitive difficulty, based on vocabulary and fund of knowledge. Memory is intact for recent and remote events and the patient is oriented to time, place, and person. There are apparent signs of anxiety. A normal attention span is in evidence and she exhibits no signs of hyperactivity. - Insight: Demonstrates good insight into her emotional patterns and coping mechanisms. Shows awareness of her impulsive behaviors and their consequences, stating "the next day I regret it" and "I get into trouble with everybody." P.F. recognizes her use of alcohol as an unhealthy coping strategy, acknowledging "that's like, no, that's not a good thing. “Judgment appears intact. Overall, she is alert and oriented x4 long term and short-term memory is intact

Physical/Vital Signs/Laboratory Data.

Vitals, Labs and Physical not done due to telehealth visit

Assessment:

Self-reporting

Emotional dysregulation, impulsivity, chronic emptiness, fear of abandonment, unstable relationships, mood instability History of childhood trauma, maladaptive coping (alcohol use, isolation, impulsive texting).

I would have completed a generalized anxiety scale and a patient health questionnaire-9 assessment.

Differential Diagnosis:

Alcohol abuse, unspecified with intoxication, unspecified (F10.929)

Rationale: P.F. isolates herself, hides out and drinks a bottle of wine when she is stressed so that she can feel like a normal person.

Presentation is consistent with borderline personality disorder, characterized by chronic emptiness, fear of abandonment, identity disturbance, impulsivity, unstable interpersonal relationships, and difficulty regulating emotions. Symptoms are understood in the context of childhood trauma and attachment disruptions, with the nervous system having developed maladaptive coping patterns in response to early neglect

Diagnosis

Borderline personality disorder, F60.3 (ICD-10) (Active)

Major depressive disorder, recurrent, mild, F33.0 (ICD-10) (Active)

Anxiety disorder, unspecified, F41.9 (ICD-10) (Active)

Post-traumatic stress disorder, unspecified, F43.10 (ICD-10) (Active)

Risk Assessment

Denies suicidal thoughts or ideations. She has no history of suicidal attempts and the risk is low.

Denies Homicidal ideations

Denies history of self-harm and has no intent. Patient is at a low risk.

Plan

Pharmacologic Management

Patient is to continue taking duloxetine 60 mg 1 tablet by mouth daily.

Rationale: Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) used to treat depression, generalized anxiety disorder, neuropathic pain, and fibromyalgia.  It is also used for stress urinary incontinence in some countries. These conditions involve some similar biological pathways. Duloxetine works by blocking the reuptake of serotonin and norepinephrine, allowing these chemicals to remain available longer between nerve cells in the brain and spinal cord. This action can help improve mood, decrease anxiety, and reduce pain (Rodrigues-Amorim et al., 2020).

Duloxetine 60 mg by mouth once daily falls within the effective dosage range reported in clinical studies. Rodrigues-Amorim et al. (2020) found that doses of 60–120 mg daily were effective in most studies reviewed.

Initiate lamotrigine 25mg 1 tablet by mouth daily.

Rationale: Lamotrigine helps with emotional dysregulation, impulsivity, chronic emptiness, fear of abandonment, unstable relationships, mood instability history of childhood trauma, maladaptive coping (alcohol use, isolation, impulsive texting).

Lamotrigine is thought to help stabilize mood by blocking voltage-gated sodium channels and decreasing the release of glutamate, a chemical involved in stimulating nerve cells. This action may reduce excessive nerve cell activity, similar to how the medication works to control seizures (Martens et al., 2024).

Lamotrigine can be a helpful option for bipolar depression, especially for maintenance treatment. One benefit is that it is generally not associated with weight gain. It is also less likely to cause sedation or problems with thinking and memory, and most patients tolerate it well. However, the provider must increase the dose slowly and monitor for rashes because of the risk of serious skin reactions, including Stevens-Johnson syndrome (Osser, 2025).

Psychotherapy Management

Refer to Cognitive Behavioral Therapy (CBT) to help identify and challenge negative automatic thoughts related to self -worth, trust and interpersonal suspicion.

Rationale: CBT can help patients who feel worthless recognize negative thoughts about themselves and question whether those thoughts are accurate. It can also help them develop more balanced thoughts and change behaviors that keep them feeling this way (Rimes et al., 2023).

Encourage P.F. to work on self-compassion and replacement of negative thought patterns.

  Lifestyle and Psychosocial Interventions

 Patient to stop drinking bottles of wine to feel better.

A. Drinking alcohol while taking antidepressants can increase side effects such as drowsiness and dizziness. It may also make treatment less effective and make it harder for patients to take their medication consistently. Duloxetine can cause liver damage, and drinking alcohol while taking it may further increase this risk (National Institute on Alcohol Abuse and Alcoholism, n.d.).

B. Sleep Hygiene: People with serious mental illness often have trouble sleeping, which can affect their daily functioning and overall well-being (Faulkner & Bee, 2016). Patient advised to establish a bed time routine. Avoid intense shows on television before bedtime and scrolling on electronic devices.

I would have include for the patient to engage in physical activity at least 3 times weekly after work and not before bed time.

Treatment Goals:

P.F. will have a decrease in impulsivity, activities within the next weeks.

P.F will have a decrease in drinking bottles of wine.

P.F will continue CBT.

P.F. will continue he monthly visits with her psychiatrist.

Education and Consent:

Verbal consent obtained from patient for consult and treatment. Patient gave consult for treatment to begin. Discussed medication management and patient aware that they are not required to take medications but if meds are prescribed, to take as ordered. Explained the benefits and possible side effects and safety of storage and use of current medication, including purpose, dose and route. Educated patient on medication risk/benefit/alternatives discussed including but not limited to black box warning, sedation, EPS, GI problems and sexual side effects. Patient advised to not drink alcohol or use recreational drugs while taking medication, negative potential effects discussed. Alternate treatment strategies discussed. Urgent/emergent procedures discussed and patient aware to call 911 in an emergency. Goals to increase stability, decrease/avoid hospitalization, increase motivation. Return 2 weeks, or earlier if needed.

 Bobbie Gilbert RN

 

                                                                                References

Faulkner, S., & Bee, P. (2016). Perspectives on sleep, sleep problems, and their treatment, in people with serious mental illnesses: A systematic review. PLOS ONE, 11(9), Article e0163486. https://doi.org/10.1371/journal.pone.0163486

Martens, M. A. G., Zghoul, T., Watson, E., Rieger, S. W., Capitão, L. P., & Harmer, C. J. (2024). Acute neural effects of the mood stabiliser lamotrigine on emotional processing in healthy volunteers: A randomised control trial. Translational Psychiatry, 14, Article 211. https://doi.org/10.1038/s41398-024-02944-6

National Institute on Alcohol Abuse and Alcoholism. (n.d.). Alcohol-medication interactions: Potentially dangerous mixes. https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/alcohol-medication-interactions-potentially-dangerous-mixes

Osser, D. N. (2025, November 14). Lamotrigine: An update on its role in bipolar disorder. Psychiatric Times, 42(11).

Rimes, K. A., Smith, P., & Bridge, L. (2023). Low self-esteem: A refined cognitive behavioural model. Behavioural and Cognitive Psychotherapy, 51(6), 579–594. https://doi.org/10.1017/S1352465823000048

Rodrigues-Amorim, D., Olivares, J. M., Spuch, C., & Rivera-Baltanás, T. (2020). A systematic review of efficacy, safety, and tolerability of duloxetine. Frontiers in Psychiatry, 11, Article 554899. https://doi.org/10.3389/fpsyt.2020.554899