Assignment 2: Focused SOAP Note and Patient Case Presentation/PRAC 6665: PMHNP Care Across the Lifespan I Practicum

Chief Complaint inpatient psychiatric evaluation for depression with suicidal ideation Legal Status: voluntary and capacitated History of Present Illness 25 year old male with past psychiatric history of unspecified mood disorder (with history of mania) and psychosis (both likely medication/substance-induced) who presented voluntarily secondary to depression and active SI and reporting attempted OD with Wellbutrin 2 days ago. He did not seek medical/psychiatric attention until presenting to crisis because he "did not have the strength." He endorsed significant depressed mood, insomnia, anhedonia, hopelessness, helplessness, decreased energy, decreased concentration, decreased appetite, and suicidal ideation. He endorsed previous suicide attempts via OD. There was no evidence of mania/hypomania or psychosis. He was subsequently admitted to MDU for psychiatric stabilization and management. The patient was seen this morning, discussed with the ancillary staff, and the chart was reviewed. Upon interview today, the patient is lying in bed, appearing sleepy, in no acute distress, appearing dysphoric, slightly irritable, and with restricted affect. He says that he attempted to overdose on bottle of Wellbutrin (cannot quantify how many pills) 2 days prior to admission because he was just released from jail about 2-3 weeks ago, has been homeless since, and "couldn't live like that anymore." He says he has been feeling significantly and severely overwhelmed by this. He says during the time between being released from jail and presentation to hospital that he was homeless, he was having significantly depressed mood, anhedonia, insomnia, decreased appetite, decreased energy, decreased concentration, worthlessness, hopelessness, helplessness, and active suicidal ideation. He endorses about 3-4 previous suicide attempts via OD, but cannot recall exactly when last one was, however says that it was about 2-3 years ago. He says that since admission yesterday, he has been having good appetite, sleeping well but says "maybe a little too much," and feels safe here in the hospital. He says he does still feel "depressed." He also endorses consistent and current everyday use of cocaine, methamphetamines, and marijuana. DAU on admission positive for cannabis and cocaine. On chart review, the majority of psychiatric admission were in the context of substance use as evidenced by positive DAUs at the time of those admissions. He says that he desires inpatient rehabilitation. He relates that prior to being in jail for about a week, he was living with some family he has that live in Miami, however he will not be able to return there upon discharge as "they don't want me back." He does not endorse current SI/HI, AVH, paranoia, or symptoms of mania/hypomania. He reports inconsistent medication compliance with his current psychotropic medication regimen of Wellbutrin XR 300 mg daily and Abilify 15 mg daily. He has no somatic complaints. Of note, Beck's Depression Inventory on admission with score of 43. Target Symptoms: Quality: depression with suicidal ideation Duration: weeks Severity: severe, interfering with ability to care for self, interfering with daily functioning, interfering with safety of self or others Context: substance abuse, homelessness, just recently released from jail, questionable medication adherence Modifying factors: therapeutic milieu, rest, no access to substances Associated S/S: depressed mood, insomnia, anhedonia, worthlessness, hopelessness, helplessness, decreased energy, decreased concentration, decreased appetite Review of Systems: General: does not endorse fevers or weight change HEENT: does not endorse sore throat or congestion Cardiovascular: does not endorse chest pain or palpitations Respiratory: does not endorse cough or wheezing Gastrointestinal: does not endorse nausea, vomiting, or changes in bowel habits Genitourinary: does not endorse dysuria or change in bladder habits Neurological: does not endorse dizziness or numbness MSK: does not endorse muscle or joint pain Past Psychiatric History:   First psychiatric visit at age 15 Previous psychiatric diagnosis: depression, psychosis, bipolar disorder, unspecified mood disorder, multiple substance use disorder Previous psychiatric hospitalizations: multiple, most recent 1/20/20-1/27/20 in ABC 1 Previous ECT: none Current outpatient psychiatrist: none Last visit to outpatient psychiatrist: years Past psychiatric medications: sertraline, risperidone, Ativan, Wellbutrin, Abilify, Remeron, Vistaril, trazodone Current psychiatric medications: Wellbutrin XL 300 mg daily and Abilify 15 mg daily Suicide history: 3 attempts by medication overdose, most recent 2020 (prior to one on current presentation)   Substance Use History:     Tobacco: does not endorse Alcohol: does not endorse Cannabis: endorses current and consistent use Cocaine: endorses current and consistent use Methamphetamines: endorses current and consistent use Opioids: does not endorse Benzodiazepines: does not endorse Amphetamines: does not endorse Hallucinogens: does not endorse Past Medical History:     does not endorse    Allergies: penicillin; cephalosporins Past Trauma History: Head trauma (TBI): does not endorse Seizure history: does not endorse Loss of consciousness: does not endorse Blackouts (substance related): does not endorse Family History: Mental illness: depression, OCD in father Suicide attempts/Completion: completed by grandmother (jumped off bridge), aunt attempted OD Substance abuse: does not endorse Social History: Born in Cuba and raised in by parents History of emotional, sexual, and/or physical abuse: does not endorse Education: 10th grade Employment status: unemployed If unemployed, makes ends meet by: unknown Living Situation: homeless Legal History: just released from jail ~2 weeks ago Support system: poor Physical Exam Vitals & Measurements T: 36.9 °C (Oral) TMIN: 36.7 °C (Oral) TMAX: 36.9 °C (Oral) HR: 53 RR: 18 BP: 109/60 SpO2: 99% Mental Status Examination Appearance: adequate grooming and hygiene, appears older than stated age Behavior: calm and superficially cooperative with interview, sleepy appearing, slightly irritable Eye Contact: poor Motor Activity: no PMA/PMR/AIMs noted Speech: normal rate, soft, low volume, with long latency Mood: "depressed" Affect: dysphoric / slightly irritable, constricted, congruent, reactive Thought Process: concrete Thought Content: slightly impoverished - Delusions: no delusions elicited - Perceptual Disturbances: does not endorse perceptual disturbances, not overtly RTIS Suicidal Ideation/Thought/Intent/Plan: does not endorse Homicidal Ideation/Thought/Intent/Plan: does not endorse Cognition - Attention/Concentration: fair/fair to interview - Orientation: awake, alert, oriented to person, location, date, situation Insight/Judgment: poor/poor Laboratory Test Results Urinalysis 06/29/2022 10:51 AM Urine Bacteria: 0 Urine Bilirubin: Neg mg/dL Urine Blood: Neg mg/dL UA Clarity: Clear Urine Color: Yellow Urine Glucose: Negative mg/dL Urine Ketones: Neg mg/dL Urine Leukocyte Esterase: Neg Urine Nitrite: Neg Urine pH: 6.0 -- Normal range between ( 4.6 and 8.0 ) Urine RBC: 1 /HPF -- Normal range between ( 0 and 3 ) Urine Urobilinogen: Negative mg/dL Urine Specific Gravity: 1.028 -- Normal range between ( 1.001 and 1.035 ) Urine Protein: 30 Urine WBC: <1 /HPF -- Normal range between ( 0 and 3 ) Mucous: Trace Urine Microscopic: Indicated Hematology 06/29/2022 10:48 AM Absolute Lymphocyte: 1.3 x10(3)/mcL -- Normal range between ( 1.1 and 2.7 ) Absolute Neutrophil: 2.7 x10(3)/mcL -- Normal range between ( 2.0 and 6.0 ) Basophil (%): 0.4 % -- Normal range between ( 0.0 and 1.2 ) Eosinophil (%): 4.1 % -- Normal range between ( 0.0 and 5.0 ) Hematocrit: 41.1 % -- Normal range between ( 39.0 and 47.1 ) Hemoglobin: 14.2 g/dL -- Normal range between ( 13.3 and 16.3 ) Lymphocyte (%): 27.6 % -- Normal range between ( 16.0 and 43.0 ) MCH: 29.8 pg -- Normal range between ( 27.1 and 33.1 ) MCHC: 34.5 g/dL -- Normal range between ( 32.2 and 36.5 ) MCV: 86.3 fL -- Normal range between ( 79.9 and 95.0 ) Monocyte (%): 10.7 % -- Normal range between ( 6.0 and 12.0 ) Neutrophil (%): 57.0 % -- Normal range between ( 36.0 and 70.0 ) Platelet Count: 183 x10(3)/mcL -- Normal range between ( 140 and 400 ) RBC Count: 4.76 x10(6)/mcL -- Normal range between ( 4.20 and 5.60 ) RDW-CV: 12.5 % -- Normal range between ( 11.0 and 15.0 ) WBC Count: 4.7 x10(3)/mcL -- Normal range between ( 4.0 and 10.5 ) MPV: 10.7 fL -- Normal range between ( 9.4 and 16.4 ) Immature Granulocyte (%): 0.2 % -- Normal range between ( 0.0 and 1.0 ) NRBC%: 0.0 /100WBC NRBC(Abs): 0.00 x10(3)/mcL Absolute Monocyte: 0.5 x10(3)/mcL -- Normal range between ( 0.3 and 0.9 ) Absolute Eosinophil: 0.19 x10(3)/mcL -- Normal range between ( 0.10 and 0.50 ) Absolute Basophil: 0.02 x10(3)/mcL -- Normal range between ( 0.01 and 0.20 ) Absolute Immature Granulocyte: 0.01 x10(3)/mcL -- Normal range between ( 0.00 and 0.10 ) Slide Review: Not Indicated General Chemistry 06/29/2022 10:48 AM Anion Gap: 6 -- Normal range between ( 6 and 22 ) Albumin Level: 4.3 g/dL -- Normal range between ( 3.9 and 5.0 ) Alkaline Phosphatase: 34 unit/L -- Normal range between ( 38 and 126 ) ALT (SGPT): 23 unit/L -- Normal range between ( 21 and 72 ) AST (SGOT): 27 unit/L -- Normal range between ( 15 and 46 ) Vitamin B12: 811 pg/mL -- Normal range between ( 232 and 1245 ) Blood Urea Nitrogen: 12 mg/dL -- Normal range between ( 9 and 20 ) Calcium Level: 9.1 mg/dL -- Normal range between ( 8.4 and 10.2 ) Cholesterol: 155 mg/dL -- Normal range between ( 150 and 200 ) Chloride: 106 mmol/L -- Normal range between ( 98 and 107 ) Calculated LDL: 64 mg/dL -- Normal range between ( 65 and 160 ) Total CO2 Content: 30 mmol/L -- Normal range between ( 22 and 30 ) CPK: 94 unit/L -- Normal range between ( 57 and 374 ) Creatinine: 1.10 mg/dL -- Normal range between ( 0.66 and 1.25 ) Folate: 8.7 ng/mL -- Normal range between ( 7.3 and 26.1 ) GGTP: 17 unit/L -- Normal range between ( 15 and 73 ) Glucose: 63 mg/dL -- Normal range between ( 74 and 106 ) Glycohemoglobin: 5.0 % A1C -- Normal range between ( 0.0 and 6.0 ) HDL: 48 mg/dL -- Normal range between ( 40 and 60 ) Potassium: 4.8 mmol/L -- Normal range between ( 3.6 and 5.0 ) Magnesium Level: 2.0 mg/dL -- Normal range between ( 1.7 and 2.2 ) Sodium: 142 mmol/L -- Normal range between ( 137 and 145 ) Osmolality Calculated: 281 mOsm/kg -- Normal range between ( 275 and 295 ) Phosphorous: 3.3 mg/dL -- Normal range between ( 2.5 and 4.5 ) Total Bilirubin: 0.5 mg/dL -- Normal range between ( 0.2 and 1.3 ) Total Protein: 6.7 g/dL -- Normal range between ( 6.3 and 8.2 ) Triglyceride: 217 mg/dL -- Normal range between ( 40 and 160 ) eGFR (Non African-American): 93 eGFR (African-American): 108 Therapeutic Drug/Tox 06/29/2022 10:51 AM Amphetamine Class: Not Detected Benzodiazepine Class: Not Detected Cannabinoid: Presumptive Positive Cocaine & Metabolites: Presumptive Positive Opiate Class: Not Detected U Phencyclidine: Not Detected U Barbiturate Class: Not Detected U Methadone: Not Detected U Oxycodone: Not Detected 06/29/2022 10:48 AM Valproic Acid Level: <10 mg/L -- Normal range between ( 50 and 100 ) Lithium Level: <0.20 mmol/L -- Normal range between ( 0.50 and 1.20 ) Ethanol Level: <10 mg/dL -- Normal range between ( 0 and 9 ) Endocrinology/Tumor Markers 06/29/2022 10:48 AM TSH: 1.640 mcIU/mL -- Normal range between ( 0.270 and 4.200 ) Infectious Disease Testing 06/29/2022 10:48 AM Syphilis IgG IgM: Non-Reactive 06/29/2022 9:30 AM SARS CoV 2 RNA, RT PCR: Negative Assessment/Plan Unspecified depressive disorder (F32.9) r/o major depressive disorder r/o bipolar disorder r/o substance/medication-induced depressive disorder Stimulant (cocaine) use disorder, severe (F14.20) Stimulant (methamphetamine) use disorder. severe (F15.20) Cannabis use disorder, severe (F12.20) Patient has acute psychiatric symptoms and is in need of treatment and stabilization. Psychiatric symptoms intolerable to patient and/or society and at risk of re-hospitalization. Patient continues to require 24 hour observation, nursing care, and inpatient treatment and cannot be treated in a less restrictive environment. In regards to patient's psychiatric symptoms, his suicidality/depressive symptoms prior to presentation are likely related to substance use and/or recent homelessness rather than primary depressive/mood disorder, especially given admission DAU positive for cannabis and cocaine, patient report of consistent/daily use of multiple substances, and history of positive DAUs during the majority of previous psychiatric admission. Therefore, the diagnosis of substance/medication depressive disorder is currently favored. Patient's current symptomatology has improved since admission and any residual symptomatology is likely a consequence of withdrawal from stimulants, and thus psychotropic medications are not currently indicated and/or needed. Will continue to monitor closely, revise differential/working diagnoses as needed, and treat as needed/indicated. Plan 1. Patient is voluntary and capacitated. 2. Medications: - no psychotropics indicated at this time as detailed above - refer to medication tab for rest of pharmacotherapy 3. Tobacco Cessation: N/A 4. Labs/Imaging: EKG pending for intermittent low BP and HR 5. Consults: none 6. Court Date: none 7. Social work evaluation for disposition and follow-up. 8. Patient was educated about reasons for prescribing the above medications, expected benefits and likelihood of clinical improvement, as well as potential side effects and relevant risks; treatment alternatives and side effects of the alternatives expected course without treatment and results of not receiving care. Patient was educated on how to take the medications. 9. Coordination of care provided with: nursing staff, treatment team: SW, CM, residents, MHTs, and physicians 10. Psycho education and support was provided. Medications, treatment plan and safety measures were discussed. Treatment team will continue to monitor adherence and follow response to treatment