Case Soap Note 2

Age: 15 years Sex: Female DOB: 7/30/2008

Associated Diagnoses: None

Basic Information

Chief Complaint: "when i get mad or sad, I do stuff I regret".

Vital signs: Vital Signs

10/2/2023 13:15 EDT	Temperature Oral	36.8 DegC
	Peripheral Pulse Rate	70 bpm
	Respiratory Rate	16 br/min
	Systolic Blood Pressure	92 mmHg
	Diastolic Blood Pressure	56 mmHg
10/2/2023 08:57 EDT	Temperature Oral	36.7 DegC
	Peripheral Pulse Rate	78 bpm
	Respiratory Rate	18 br/min
	Systolic Blood Pressure	98 mmHg
	Diastolic Blood Pressure	70 mmHg
10/2/2023 08:30 EDT	Temperature Oral	36.7 DegC
	Respiratory Rate	18 br/min
10/2/2023 08:30 EDT	Peripheral Pulse Rate	78 bpm
	Systolic Blood Pressure	98 mmHg
	Diastolic Blood Pressure	70 mmHg
	Mean Arterial Pressure, Cuff	80 mmHg

, Oxygen saturation: Basic Oxygen Information

10/2/2023 13:15 EDT	Oxygen Therapy	Room air
	SpO2	100 %
10/2/2023 13:00 EDT	Oxygen Therapy	Room air
10/2/2023 08:57 EDT	SpO2	99 %
10/2/2023 08:30 EDT	SpO2	99 %

.

Allergies:

Allergic Reactions (Selected)

NKA.

History of Present Illness

Ms. Pena is a 15 year old female with PPHx of depression, anxiety, and ADHD who was transferred from Jackson South involuntarily under BA by police due to suicidal ideation in the setting of interpersonal problems with her older brother. Per DrFirst, patient prescribed lexapro 10 mg daily, abilify 10 mg daily, atomoxetine 40 mg daily, and vistaril 50 mg.

Prior to interview, patient observed resting comfortably in triage area, tearful, with her head down, eye makeup smeared from crying. Upon interview, patient was calm and cooperative, goal-directed and answering questions logically and linearly. She reports having an altercation with her brother this morning when he asked her to take out the trash prior to giving patient a ride to school. Patient reports that tensions escalated in the car ride to school when patient's brothers began recording her while she was upset, which allegedly led to patient physically assaulting her brother, then brother stopping the car and dragging patient out onto the side of the road. Patient reports that in the process, her top came off, she subsequently felt nauseous and began vomiting, and had thoughts of self harm. She called the police for help and was taken to the hospital. She endorses chronic history of depression since she was 11 years old, associated with difficulty sleeping, anhedonia, poor appetite, heightened guilt, trouble concentrating, and intermittent passive death wishes. She admits to forgetting to take her medications consistently and does not feel they have significantly helped her mood. She endorses history of intermittent self-injurious behavior via cutting since age 7, last cut herself in August (reveals old scars on upper left arm) and reports it relieves anger/frustration. She denies current suicidal thoughts/intent/plans, though appears visibly depressed on exam. She endorses anxiety and reports trouble making eye contact with others, giving public speeches. She denies HI/AH/VH, does not appear to be responding to internal stimuli on exam. She endorses history of bullying and history of sexual abuse, between age 6-12, by a member who still lives with her today. This is the first time she has shared this information with someone other than her closest friend. Patient currently lives with her mother, step father, two older brothers, and one younger sister. She endorses hypervigilance around men, intrusive memories of the event, avoidance of stimuli associated with the event. She endorses frequent cannabis use which she states is one of her primary coping mechanisms.

Collateral information obtained by patient's mother (Rosalina Martinez 305-763-7457): Mother reports that for the past few years, patient has been experiencing emotional breakdowns (angry outbursts or crying spells) which has worsened in the past few months associated with poor grades in school. She reports patient has been hospitalized once, at Larkin, in June 2023 for 10 days due to suicidal ideation and was discharged on lexapro and abilify. Patient follows with an outpatient psychiatrist and was scheduled for an appointment this afternoon. Patient has been in weekly therapy for 4 months. Mother corroborates the verbal dispute between patient and her brother regarding household chores and admits her sons are often hard on the patient. Mother denies history of suicide attempts or self injurious behavior, though has heard patient voice suicidal ideation, most recently earlier today. She reports that patient is self-isolative at home, does not have many friends, and often needs encouragement to bathe. Mother is aware of patient's cannabis use. She denies history of trauma other than parents divorce when patient was at a young age. She consents to psychotropic medication.

Past Medical/ Family/ Social History

Psychiatric history: Anxiety, depression, ADHD.

Substance Use History: Alcohol: Denies alcohol use, Tobacco: Denies tobacco use, Drugs: Marijuana.

Medical history: Reviewed as documented in chart.

Surgical history: Reviewed as documented in chart.

Family Medical history: Reviewed as documented in chart.

Social history:

Social & Psychosocial Habits

Tobacco

10/02/2023 Smoking tobacco use: Never tobacco user

Smokeless tobacco use: Never

Substance Abuse

10/02/2023 Use: Denies substance abuse

Alcohol

10/02/2023 Use: Denies alcohol use

Abuse/Neglect/Domestic Violence

10/02/2023 Injuries/Abuse/Neglect in household: No, No apparent signs of abus

Hit, slapped, kicked, punched, choked, or physically hurt yo No, No apparent signs of abus

Threatened you or made you feel afraid: No, No apparent signs of abus

Touched you or forced you to have sex in a way you did not w No, No apparent signs of abus

Refused you food, medicines, or medical aids: No, No apparent signs of abus

Feels safe at home: Yes

Safe place to go: Yes

Electronic Cigarette/Vaping

10/02/2023 Use Never

, Reviewed as documented in chart.

Review of Systems

Constitutional: Denies fever, chills, sweats

Skin: Denies rash

Eye: Denies pain

ENT: Denies ear pain, sore throat, nasal congestion, rhinorrhea

Cardiovascular: Denies chest pain, palpitations

Respiratory: Denies shortness of breath

Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation

Genitourinary: Denies dysuria,

Musculoskeletal: Denies muscle pain, joint pain

Neurologic: Denies numbness, tingling, weakness

Physical Examination

General appearance: Mild distress.

Eye: Within normal limits

Neck: Trachea midline.

Respiratory: Respirations nonlabored

Abdominal: Non distended

Extremity: Normal range of motion

Neurological: Alert

Medical Decision Making

Clinical work-up/Interpretation

Results: Lab View

10/2/2023 09:48 EDT	Estimated Creatinine Clearance	143.92 mL/min/1.73m2
10/2/2023 08:45 EDT	Glucose	89 mg/dL
	Sodium	138 mmol/L
	Potassium	3.5 mmol/L
	Chloride	104 mmol/L
	Total CO2 Content	17 mmol/L LOW
	Anion Gap	17
	Osmolality Calculated	276 mOsm/kg
	Blood Urea Nitrogen	12 mg/dL
	Creatinine	0.60 mg/dL
	Calcium Level	10.3 mg/dL
	Total Protein	8.5 g/dL HI
	Albumin Level	5.4 g/dL HI
	Total Bilirubin	1.1 mg/dL
	AST (SGOT)	28 unit/L
	ALT (SGPT)	20 unit/L
	Alkaline Phosphatase	68 unit/L
	eGFR FAS-EKFC	>90 NA
	Glycohemoglobin	4.6 % A1C
	Cholesterol	155 mg/dL
	Calculated LDL	77 mg/dL
	HDL	64 mg/dL HI
	Triglyceride	71 mg/dL
	CPK	84 unit/L
	Serum Pregnancy (QUALITATIVE)	Negative
	WBC Count	6.3 x10(3)/mcL
	RBC Count	4.55 x10(6)/mcL
	Hemoglobin	13.2 g/dL
	Hematocrit	38.4 %
	MCV	84.4 fL
	MCH	29.0 pg
	MCHC	34.4 g/dL
	RDW-CV	12.7 %
	Platelet Count	317 x10(3)/mcL
	MPV	10.0 fL
	NRBC%	0.0 /100WBC
	NRBC(Abs)	0.00 x10(3)/mcL
	NEUT%	75.1 % HI
	LYMPH%	17.4 %
	MONO%	6.3 %
	EO%	0.6 %
	BASO%	0.3 %
	IG%	0.3 %
	NEUT(Abs)	4.7 x10(3)/mcL
	LYMPH(Abs)	1.1 x10(3)/mcL LOW
	Mono Auto Abs	0.4 x10(3)/mcL
	Eos Auto Abs	0.04 x10(3)/mcL LOW
	Baso Auto Abs	0.02 x10(3)/mcL
	IG Auto Abs	0.02 x10(3)/mcL
	TSH	0.364 mcIU/mL
	SARS CoV 2 RNA, RT PCR	Negative
	Ethanol Level	<10 mg/dL

.

Plan:

-Admit to Inpatient, Involuntary and Incapacitated

-Meds:

-Psychotropic: lexapro 10 mg daily, PRN melatonin, vistaril

-Medical: PRN albuterol

-Labs: UA, DAU (other labs completed at Jackson South)

-Safety: No 1:1 sitter acutely indicated at this time. Continue current level of inpatient staff observation. Discussed with team and will continue to monitor and treat as indicated.

Chief Complaint

"He was taking pictures of me"

HPI

Quality: Depression

Duration: Months

Timing: acute on chronic

Severity: interfering with safety of self or others

Context: precipitating stressor for admission & Questionable medication adherence

Modifying factors: medications, therapeutic milieu

Associated signs and symptoms: see HPI & MSE Ms. Pena is a 15 year old female with PPHx of depression, anxiety, and ADHD who was transferred from Jackson South involuntarily under BA by police due to suicidal ideation in the setting of altercation with brother. Prior to interview, patient observed resting in common area. She reports having an altercation with her brother the day prior. Patient reports that while in the car with her brother, brother was "antagonizing" patient. Despite her attempts to make her brother stop, brother continued to to escalate tensions, whereby brother "swung at patient." Patient physically retaliated, leading to brother stopping the car and dragging patient out onto the side of the road by her hair. Patient reports that in the process, her top came off, and that while she was agitated, and walking away, her brother began filming her. In "the heat of the moment" had thoughts of self harm. She called the police for help and was taken to the hospital. Patient reports that she "gets heated" rarely, and that these occur as a result of "her past" as well as "provocation." While patient endorses hypervigilance around men, intrusive memories, avoidance of stimuli associated with the event, patient seems to believe "she is not affected by it," and seemed to be minimizing the effects of the abuse. She endorses chronic history of depression since she was 11 years old, associated with difficulty sleeping, anhedonia, poor appetite, heightened guilt, trouble concentrating, and intermittent passive death wishes. She admits to forgetting to take her medications consistently and does not feel they have significantly helped her mood. She endorses history of intermittent self-injurious behavior via cutting since age 7, last cut herself in August (reveals old scars on upper left arm) and reports it relieves anger/frustration. This morning, she adamantly denies current suicidal thoughts/intent/plans. . She denies HI and AVH, does not appear to be responding to internal stimuli on exam. She endorses history of bullying and history of sexual abuse, between age 6-12, by a member who still lives with her today, though she stated she did not want to disclose who it was. She endorses daily cannabis use which she states is one of her primary coping mechanisms. Collateral information obtained by patient's mother (Rosalina Martinez 305-763-7457) was contacted to renew psychotropic consent.

Past Psychiatric History

Inpatient treatment: one 10 day admission at Larkin

Outpatient treatment: Sees outpatient psychiatrist once a month

Suicide History: None

Past psychiatric medications:

Current psychiatric medications: Lexapro, Atomoxetine

Medical History

Past medical history: denies

Past surgical history: denies

Seizures: denies

Loss of consciousness: denies

Traumatic brain injury: denies

Current nonpsychiatric medications: None

Allergies NKA

Substance Use History

Tobacco: denies

Alcohol: denies

Cannabis: denies

Cocaine: denies

Opioids: denies

Benzodiazepines: denies

Amphetamines: denies

Hallucinogens: denies

Detox/Rehab: denies

Trauma History

Physical: denies

Sexual: denies

Neglect: denies

Family History

Mental illness: denies

Suicide attempts: denies

Substance abuse: denies

Medical problems: denies

Developmental History

Birth history: vaginal, reached all developmental milestones

Psychosocial History

Born: Miami

Raised: Miami, Florida

Siblings: Two older brothers

Lives with: Mother, stepfather and two older brothers

Relationship: Single

Use of contraceptives: NA

Educational History

Grades: Average performance

Suspensions: None

Legal History

Legal guardian: parents

History of arrest: None

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

Last Menses:

Vital Signs

Temperature

36.5 (06:32)

Systolic Blood Pressure

82 (06:32)

Diastolic Blood Pressure

55 (06:32)

Pulse

83 (06:32)

SpO2

98 (06:32)

Respiratory Rate

16 (06:32)

Mental Status Exam

Appearance: adequate grooming and hygiene, appears stated age

Behavior: calm, cooperative with interview

Orientation: awake, alert, oriented to person, location, date, situation

Speech: normal rate, volume

Eye Contact: Fair

Motor Activity: no PMA/PMR/AIMs noted

Mood: "depressed"

Affect: Constricted, mood-congruent

Thought Process: organized

Thought Content: no delusions, preoccupations, obsessions, or compulsions elicited

Suicidal Ideation: denies SI

Homicidal Ideation: denies HI

Perceptual Disturbances: denies perceptual disturbances, not RTIS during interview

Insight/Judgment: poor/poor

Attention/Concentration: fair/fair to interview

Memory: not formally testedFund of knowledge: baseline

Medical Decision Making

DSM-5 Diagnosis:

PTSD F43.1

Depressive Disorder Unspecified F32.9

Anxiety Disorder Unspecified F41.9

Sertraline 25mg PO daily DCF case accepted, follow up DC Esctialoprtam

Problem List/Past Medical History Ongoing Head injury Historical

No qualifying data Medications Inpatient acetaminophen Pedi, 325 mg= 1 tab, ORAL, Q6H, PRN albuterol 90 mcg/inh inhalation aerosol, 180 mcg= 2 puff, INHALATION, Q6H, PRN Lexapro, 10 mg= 1 tab, ORAL, DAILY melatonin, 5 mg= 1 tab, ORAL, BEDTIME, PRN Vistaril, 50 mg= 1 cap, ORAL, Q6H, PRN Home

No active home medications Allergies NKA Social History

Abuse/Neglect/Domestic Violence

Injuries/Abuse in household: No, No apparent signs of abuse. Hit, slapped, kicked, punched, choked, or physically hurt you: No, No apparent signs of abuse. Threatened you or made you feel afraid: No, No apparent signs of abuse. Touched you or forced you to have sex in a way you did not want: No, No apparent signs of abuse. Refused you food, medicines, or medical aids: No, No apparent signs of abuse. Feels safe at home: Yes. Safe place to go: Yes., 10/02/2023

Alcohol

Use: Denies alcohol use., 10/02/2023

Electronic Cigarette/Vaping

Use: Never., 10/02/2023

Substance Abuse

Use: Denies substance abuse., 10/02/2023

Tobacco

Never tobacco user, Smokeless tobacco use: Never., 10/02/2023