SOAP PP

HPI: The patient is a 67-year-old female who was brought to the clinic by her concerned daughter. The patient has a history of type 2 diabetes mellitus, which was diagnosed when she was 34 years old. The patient admitted to losing her spouse of 40 years two months ago, and ever since, things have been different. She admitted that she attributed her symptoms of sadness to the loss of her husband, but the feeling has progressively worsened and is accompanied by other symptoms. The patient admitted that she is constantly feeling anxious and trapped and does not know what to do with her life anymore. She admitted to feeling fatigued but could not sleep and spent most of the night tossing and turning. She admitted to crying easily and has, on occasion, entertained thoughts of suicide. She admitted that she has also had a reduction in appetite and has lost a few pounds over the course of two months. She admitted to physical symptoms such as headaches, sweating, and body aches. The patient denied knowing of any relieving factors that could help alleviate her current symptoms. The patient rated the severity of her symptoms at 7/10 due to their negative impact on her daily life. She admitted to taking Metformin 500 mg, taken orally twice daily, for the management of her Type 2 diabetes mellitus. She has been on this medication ever since she was diagnosed at age 34. She denied fever, nausea, stomachaches, or heart palpitations.

SI/HI: She admitted to occasionally entertaining thoughts of suicide.

Sleep: She admitted to never having trouble sleeping until two months ago. She admitted to having trouble falling asleep even though she is constantly fatigued   Appetite: She admitted to a reduction in appetite and losing a couple of pounds over the course of two months.

Allergies (Drug/Food/Latex/Environmental/Herbal): The patient denied any known allergy to drugs, food, latex, environment, or herbal. Current perception of Health Excellent Good Fair Poor

Psychiatric History:

Inpatient hospitalizations:

Outpatient psychiatric treatment:

Detox/Inpatient substance treatment:

History of suicide attempts and/or self-injurious behaviors: She denied any history of suicidal attempts or engaging in self-injurious behaviors.

Past Medical History

· Major/Chronic Illnesses: The patient admitted to being diagnosed with type 2 diabetes mellitus when she was 34 years old. She admitted that the condition is currently active.

· Trauma/Injury: She admitted to occasional falls and injuries that resulted in minor bruises.

· Hospitalizations: She denied any history of hospitalization.

Past Surgical History: She admitted to undergoing a tonsillectomy to remove her tonsils due to enlarged tonsils that were obstructing her airway when she was 24 years old.

Current psychotropic medications:

_______________________None__________________ ________________________________

_________________________________________ ________________________________

Current prescription medications:  

Metformin 500 mg is taken every day in the morning and evening as part of her ongoing treatment for T2DM. ________________________________ ________________________________

_________________________________________ ________________________________

OTC/Nutritionals/Herbal/Complementary therapy:

______________None___________________________ ________________________________

_________________________________________ ________________________________

Substance use : (alcohol, marijuana, cocaine, caffeine, cigarettes)

Family Psychiatric History:

· The patient admitted that her father, who died when he was 70 years old, had a history of social anxiety disorder, which he managed with medication and psychotherapy.

· The patient admitted that her mother, who died when she was 83 years old, had a history of major depressive disorder. She managed this condition with both medication and psychotherapy. She also had a history of adjustment disorder, which she managed with psychotherapy.

· The patient admitted that her elder brother, who is 74 years old, has a history of alcohol use disorder and has been on and off rehab over the years.

· The patient’s nephew, who is currently 5 years old, was diagnosed with autism spectrum disorder, which he manages with medication and psychotherapy.

Social History

Lives: Single-family House/Condo/ with stairs: __ 5-bedroom family house __ Marital Status: Widow _______

Education: ______ Bachelor of Science in nursing __

Employment Status: Employed Current/Previous Occupation type: Pediatrician at the Nicklaus Children's Hospital.

Exposure to: _Denies__ Smoke_ Denies___ ETOH __Denies__ Recreational Drug Use: Denies

Sexual Orientation: Heterosexual ___ Sexual Activity: _ Not Active_ Contraception Use: __ None___

Family Composition: Family/Mother/Father/Alone : ___ The patient admitted that both her parents are not alive. Her brother and two sisters live in different states. His three children are grown, and two of them are married and living in different states. She currently lives with her last-born daughter and two dogs.

Other: (Place of birth, childhood hx, legal, living situations, hobbies, abuse hx, trauma, violence, social network, marital hx): The patient admitted that she was born in Arkansas, but she relocated to Miami, Florida, after she got married. The patient admitted to having had a happy childhood, even though they were not financially stable. She admitted to being arrested for shoplifting when she was 17 years old. She denied any other criminal or legal misconduct. She admitted that she lives in a five-bedroom family house with her last-born daughter and two pet dogs. She admitted that she used to enjoy running and playing tennis whenever she got the chance but has not engaged in any of these activities for the past two months. She admitted that her husband and she were well-loved and made a lot of friends. She admits to being socially withdrawn ever since her husband died. She denied a history of abuse, trauma, or violence. She admitted to only being married once, and she was married for 30 years until recently.

Health Maintenance

Screening Tests

· The patient received the Beck Depression Inventory (BDI) screening on December 23, 2020, and her score was 5, which was negative for any significant depression symptoms.

· The patient received the GAD-7 screening test on October 13, 2020, and her score was 3, indicating minimal anxiety levels.

· The patient received her annual checkup on the 4th of December, and she was in good health and negative for any abnormalities.

· She admitted that she received a 6-month dental checkup on October 16, 2020, and the results were negative for any gum or mouth disease. She admitted to receiving education on good oral hygiene.

Exposures: She denies being exposed to any harmful substances currently or in the past.

Immunization HX:

The patient admitted that she is up to date on all immunizations, including the shingles vaccine and the COVID-19 booster vaccine. She, however, denied receiving the annual flu vaccine and the pneumococcal vaccine.

Review of Systems (at least 3 areas per system):

General: The patient admits to feelings of sadness, hopelessness, lack of sleep, fatigue, crying a lot, headaches, and feeling trapped.

HEENT: The patient admits to occasional headaches. She denies any head injuries or recent vision changes. She denies eye redness or double vision. She admits mild hearing loss but denies recent ear infections or injuries.

Neck: The patient denies any neck stiffness, lumps, or pain. She admits occasional muscle tension in the neck and shoulders.

Lungs: The patient denies any shortness of breath, cough, or chest pain.

Cardiovascular: The patient denies experiencing palpitations, a history of heart disease, or high blood pressure.

Breast: The patient denies any breast lumps, pain, or nipple discharge.

GI: The patient admits to having occasional indigestion. She denies any difficulty swallowing, nausea, or vomiting. She admits to significant changes in appetite and weight.

Male/female genital: She denies vaginal itchiness, discharge, or sores.

GU: The patient denies any urinary frequency, urgency, or pain. She denies any recent urinary tract infections or kidney issues.

Musculoskeletal: The patient admits experiencing muscle tension and occasional joint discomfort. She denies any recent injuries or limitations in movement.

Activity & Exercise: The patient admits to decreased motivation for exercise and physical activity. She denies any exercise-related injuries or physical limitations

Psychosocial: The patient admits feeling overwhelmed and struggling to cope with life's changes. She admits to suicidal thoughts but denies making suicide attempts.

Derm: The patient denies any skin rashes, lesions, or itching.

Nutrition: The patient admits to a decreased appetite over the past two months. She also admitted to significant weight loss. She admitted to drinking 7–8 glasses of water each day.

Sleep/Rest: She admits to having trouble falling asleep and staying asleep due to constant worry.

LMP: She admitted that her last menstruation was 26 years ago. She admitted that her menstruation was often irregular, occurring every 3–4 months. She admitted that the menstrual flow was usually heavy and was accompanied by stomach cramps.

STI Hx: The patient denied a history of sexually transmitted infections, urinary tract infections, or abnormal vaginal discharge.

Physical Exam

BP__130/80 mmHg measured when the patient was in a seated position______TPR_97.3F measured through the mouth___ HR: ___78__ RR: _20___Ht. _167.6 cm____ Wt. ___68 kg___ BMI ( percentile) __24,2 kg/m2 (Normal range) ___

General: Alert and oriented to time, place, and person. Reports feelings of stress and anxiety due to recent life changes. She has a well-groomed appearance but is restless during the examination. No signs of acute distress

HEENT: The head is normocephalic and atraumatic; no dry scalp or dandruff were noted. Pupils are equal and responsive to light. Extraocular movements are intact, but the patient reports occasional blurry vision. External ears are symmetrical without lesions or discharge. Tympanic membranes are translucent with no bulging and are reactive to light. Oropharynx pink and moist; no exudate or tonsillar enlargement. Teeth are white and evenly distributed. Uvula midline, and no cracking or abnormalities at the corners of the mouth.

Neck: Mild neck tenderness on palpation, likely due to muscle tension. Cervical lymphadenopathy was not observed. No neck stiffness or swelling was observed.

Pulmonary: Mild respiratory rate elevation due to anxiety Bilateral chest expansion is present and equal. Clear breath sounds on auscultation bilaterally. No wheezing, crackles, or rhonchi.

Cardiovascular: Regular rate and rhythm without murmurs Mild tachycardia due to anxiety. No jugular venous distension Peripheral pulses are equal and symmetric.

Breast: On inspection, there are no palpable masses or lumps detected in either breast. The skin appears smooth and without any visible abnormalities, such as redness, dimpling, or nipple retraction. The nipples are bilaterally symmetrical and do not show any signs of discharge.

GI: The abdomen is soft, with mild tenderness on deep palpation due to anxiety. Bowel sounds are present in all quadrants. No organomegaly on palpation No hernias or masses were found on inspection.

GU: The external genitalia appear normal and well-developed. There are no visible lesions, ulcers, or abnormal growths. The labia majora and minora are symmetrical and without swelling. The clitoris is normal in size and not tender upon palpation

Neuro: Alert and oriented to person, place, and time. Cranial nerves 2–12 are intact and functioning appropriately, but the patient reports occasional headaches. Good muscle tone and strength in all extremities. Facial muscles are symmetric and exhibit normal strength and tone. No involuntary movements, tremors, or fasciculations are observed. Deep tendon reflexes (DTRs) are 2+ and symmetric in the upper and lower extremities. Babinski reflex is negative bilaterally.

Musculoskeletal: The patient stands with a normal, erect posture; gait is steady and coordinated, with a smooth heel-to-toe motion; the spine appears straight without any noticeable curvature; limbs are symmetrical in length and size, with no obvious deformities or discrepancies; and muscle bulk appears appropriate for the patient's age and activity level.

Derm: The skin is clean, warm, and dry, without rashes or lesions, and there is no evidence of ecchymosis or petechiae.

Psychosocial: The patient is alert and aware of the time, place, and person. Feelings of frustration and difficulty adapting to recent life changes were noted, and a history of suicidal thoughts was reported.

Misc.: No additional information was collected.

Mental Status Exam

Appearance: The patient appears sad and fatigued but with good body hygiene. She is able to hold a conversation and maintain good eye contact.

Behavior: The patient is attentive and cooperative during the evaluation.

Speech: The patient's speech is clear and coherent.

Mood: The patient presents with a sad, easily irritable, and anxious mood.

Affect: The patient's affect is congruent with her mood, displaying signs of sadness and worry.

Thought Content: The patient expresses concerns related to recent life changes and struggles to adjust to life without her husband.

Thought Process: She is able to express herself effectively and convey her emotions and experiences in a clear and organized manner

Cognition and Intelligence: The patient's cognitive functioning appears unimpaired, and she is oriented to time, place, and person.

Clinical Insight: The patient’s insight is unimpaired. She recognizes her difficulties in adjusting to recent life events

Clinical Judgment: The patient's judgment is relatively intact, but she may benefit from support and coping strategies.

Plan:

The International Adjustment Disorder Questionnaire

The International Adjustment Disorder Questionnaire: The patient score of 25/30 indicated severe symptoms of adjustment disorder.

Thyroid Function Tests (TFTs):

· TSH: 32.0 mIU/L (Normal Range)

· FT4: 1.3 ng/dL (Normal Range)

· FT3: 3.0 pg/mL (Normal Range)

Comprehensive Metabolic Panel (CMP):

· Blood Glucose: 82 mg/dL (Normal Range)

· Sodium: 139 mmol/L (Normal Range)

· Potassium: 4.0 mmol/L (Normal Range)

· AST (SGOT): 24 U/L (Normal Range)

· ALT (SGPT): 18 U/L (Normal Range)

· Creatinine: 0.7 mg/dL (Normal Range)

Differential Diagnoses

1. Major Depressive Disorder DSM-5 296.20 (F32)

Major depressive disorder is a mood disorder characterized by persistent feelings of sadness and a decreased desire to perform previously enjoyed activities (Widge et al., 2019). Additional depressive symptoms include changes in appetite, difficulty sleeping, fatigue, decreased energy level, and feelings of worthlessness, guilt, and irritability. Even though the patient’s presenting symptoms suggest this condition, the screening tool rules it out.

2. Generalized Anxiety Disorder (GAD), DSM-5 300.02 (F41.1)

Generalized anxiety disorder is a mental condition that occurs at any age and is characterized by excessive feelings of worry about everyday things (Lotzin, 2020). In addition to feeling worried, a person may also feel restlessness, fatigue, trouble concentrating, irritability, increased muscle tension, and trouble sleeping. The screening tool ruled out this condition.

Principal Diagnoses

Adjustment Disorder DSM-5 code 309.9 (F43.9)

Adjustment disorder is identified as a short-term condition that occurs when a person experiences an extreme emotional reaction to a stressful situation or change in their life (Lotzin et al., 2020). Adjustment disorder symptoms include both emotional and physical symptoms. They include fatigue, headaches, sweating, stomachaches, being anxious or agitated, feeling trapped or hopeless, crying easily, trouble concentrating, being withdrawn or isolated, lacking energy or enthusiasm, and loss of interest in everyday activities

Treatment Plan

According to US guidelines, medication is not considered the first-line treatment option for a person with adjustment disorder (Dragan et al., 2021). However, to manage the patient’s anxiety and depressive symptoms, she was prescribed Fluoxetine 10 mg, taken orally once a day. cognitive-behavioral therapy to help the patient identify and manage negative thinking patterns. The cost for fluoxetine oral capsules 20 mg is around $4 for a supply of 30 capsules

Plan:

Diagnosis #1: Adjustment Disorder

Diagnostic Testing and Screening: The International Adjustment Disorder Questionnaire

Pharmacological Treatment:

Name: Fluoxetine

Dosage: 10 mg

Route: By mouth

Frequency: Once a day

Cost: The cost for fluoxetine oral capsule 20 mg is around $4 for a supply of 30 capsules

Non-Pharmacological Treatment: Cognitive-Behavioral Therapy

Patient/Family Education:

1. Practice deep breathing for relaxation.

2. Engage in regular physical activity.

3. Set realistic daily goals.

4. Seek social support from friends and family.

5. Limit exposure to stressful situations.

6. Practice mindfulness meditation.

7. Keep a journal to express emotions.

Referrals: Psychotherapist

Follow-up: 1 week to assess the effectiveness of the medication.

Anticipatory Guidance:

1. Prioritize self-care and rest.

2. Challenge negative thoughts.

3. Establish a consistent sleep schedule.

4. Limit caffeine intake.

5. Avoid excessive use of electronic devices.

6. Take short breaks during the day.

7. Engage in enjoyable hobbies or activities.

Signature (with appropriate credentials): __________________________________________

Cite current evidence-based guideline(s) used to guide care (Mandatory) ____

References