65.Wk4N

SOAP Note and Patient Case Presentation

Ryan Keller

Walden University

6665 PRAC

Faculty Name

Due 6/20/21

Subjective:

CC (chief complaint): “I’m feeling a bit anxious and I have difficulty sleeping.”

HPI: A.N. is a 31-year-old Caucasian female presenting for evaluation of anxiety. She is currently on low-dose olanzapine, Antabuse, and BuSpar that have improved her anxiety symptoms significantly. She describes the severity of her anxiety as a 4/10 and sleep difficulty a 7/10. The anxiety and the sleeping problems started three years ago. She worried about different things and felt irritable for no reason. The symptoms are constant and they are not associated with any activity. In the beginning, A.N. would read novels or watch movies to calm herself and sleep but it was ineffective. She then started abusing alcohol one year ago to promote sleep and manage anxiety. Trazodone and Remeron were also ineffective. The patient reports that BuSpa and olanzapine have improved her sleep and anxiety. She says the anxiety is associated with lack of sleep, increased heart rate and breathing, and feelings of impending doom.

Past Psychiatric History:

· General Statement: The patient is admitted and she is being treated for alcohol use.

· Caregivers (if applicable): No caregivers.

· Hospitalizations: She denies past hospitalizations, detox, residential treatment, or hospitalizations for alcohol withdrawal. No reports of self-harm, suicidal, or homicidal ideations.

· Medication trials: Patient has used trazodone and Remeron but they did not agree with her.

· Psychotherapy or Previous Psychiatric Diagnosis: She has a history of alcohol use disorder, generalized anxiety disorder, and depressive disorder. The patient had also received a bipolar 2 disorder diagnosis in the past. She denies receiving psychotherapy in the past.

Substance Current Use: A.N. reports using drinking at least four alcoholic drinks every day and she last used five days ago. She denies a history of tremors, Delirium Tremens, and other withdrawal symptoms. However, she had a seizure this week. She also takes a cup of tea every morning. The patient denies using nicotine, marijuana, or other illegal substances.

Family Psychiatric/Substance Use History: Patient does not have a family history of suicides, substance abuse, or psychiatric conditions.

Psychosocial History: A.N. was born in Pittsburgh where she grew up with her parents and two sisters. She is the first born in a family of three. Patient is single, no children, and lives alone. Her parents live in a nearby neighborhood.

Educational Level: University graduate

Hobbies: Reading, movies, and gardening

Work History: Currently working as an accountant but she has received a warning because of alcoholism and absenteeism

Legal history: No reports of current or past legal problems.

Trauma history: She denies a history of childhood or adult trauma.

Violence Hx: Denies current or past personal, home, physical, or community violence.

Medical History: Patient denies any medical conditions including head injuries or surgeries. She experienced a seizure this week.

· Current Medications: Patient is currently on low-dose olanzapine at bedtime, and BuSpar 15 mg twice a day for anxiety for the last six months. She is also on Antabuse for alcohol use disorder for the past one week. She denies use of OTC or homeopathic products.

· Allergies: No known environmental, food, or medication allergies.

· Reproductive Hx: Date of LMP: 6/6/2021. Patient is not pregnant or nursing. A.N. is single, sexually inactive and she is not using any contraceptives. She denies any sexual concerns or history of STDs.

ROS:

· GENERAL: Reports of fatigue. Negative for appetite and weight changes, fever, or chills.

· HEENT: Denies yellow sclera, vision issues, hearing problems, runny nose, or sore throat.

· SKIN: No reports of blisters, itching, hives, or rashes.

· CARDIOVASCULAR: Reports increased heart rate and chest tightness but denies chest pain.

· RESPIRATORY: Positive for faster breathing. Negative for cough and sputum. No history of asthma, pneumonia, or COPD.

· GASTROINTESTINAL: Reports nausea but denies stomach pain, or diarrhea, vomiting.

· GENITOURINARY: Negative for incontinence or changes in urinary patterns, odor, or odd color.

· NEUROLOGICAL: No numbness, bladder and bowel control changes, dizziness, or headaches.

· MUSCULOSKELETAL: Denies joint, bine, and muscle pain.

· HEMATOLOGIC: No anemia, excessive bleeding, or easy bruising.

· LYMPHATICS: Denies enlarged nodes.

· ENDOCRINOLOGIC: No history of diabetes, endocrine conditions, or cold and intolerance.

· PSYCHIATRIC: Reports sleep difficulties and anxiety. History of depression.

Objective:

Physical exam:

VS: BP 118/78; P 75; RR 20 non-labored; T 98.5 orally; 98%; Wt 119 lbs; Ht 5’6

General: She is alert and oriented x3. Appears happy and cooperative.

HEET: Head: Negative for injuries and swellings. Eyes: Clear, no bleeding, or yellow sclera. Ears: No discharge or bleeding.

Neck: Full range of motion with no pain, swelling, or palpable nodes.

Chest/Lungs: Symmetrical chest expansion. Clear to auscultation

Cardiovascular: No gallop, edema, or rub. RRR.

Gastrointestinal: No palpable liver or masses. All four quadrants have quality bowel sounds.

Neurological: Clear speech; cranial nerves II – XII are intact.

Skin: Negative for rashes, hives, color changes, swelling, or bruising.

Diagnostic results:

Normal brain CT scan

Normal thyroid tests

Normal ECG or EKG tests

Blood alcohol concentration (BAC) negative

A score of 3 on the Cage screening test

Negative urine drug test

A score of 10 on the GAD-7 diagnostic tool

A brain CT scan is necessary to eliminate brain and neurological disorders that might mimic anxiety symptoms. Thyroid problems could also make people anxious; hence, the need to perform thyroid tests (Brahmbhatt et al., 2020). Some cardiovascular conditions are also differential diagnoses for generalized anxiety disorder (Brahmbhatt et al., 2020). ECG and EKG tests were done to rule out cardiovascular problems. Moreover, the patient is being treated for alcohol use disorder. Therefore, blood alcohol concentration (BAC) test is vital to determine if the patient is still taking alcohol. The urine drug test was to detect substance abuse, which is a differential diagnosis for anxiety (Brahmbhatt et al., 2020). Finally, GAD-7 is a diagnostic tool for detecting the severity of anxiety in patients (Brahmbhatt et al., 2020).

Assessment:

Mental Status Examination:

She is a 31-year-pld Caucasian female who is well-groomed and casually dressed. The patient is cooperative, makes good eye contact, smiles, and jokes appropriately. She is not lethargic or psychomotor agitated. The patient has a clear and coherent speech with normal tone and volume. Her affect is superficially bright. She is upbeat and hopeful for the future, her racing thoughts have seemed to decrease, and she says she feels more "mellow. “The patient denies depressive cognition, suicidal or homicidal ideations. She does not indicate flight of ideas or looseness of associations. There is no evidence of paranoia or delusions and she denies hallucinations. The patient is attentive, oriented, alert, and with good concentration. Her insight and judgement are good. She has intact recent and remote memory.

Diagnostic Impression:

1. Generalized Anxiety Disorder (GAD)

A.N. meets all the criteria for GAD. Firstly, she says she feels anxious, has racing thoughts, and worries about different things. She scored a 10 on GAD-7 and rates the severity of her anxiety as a 4/10. A score of about 10 and above on GAD-7 diagnostic tool indicates moderate anxiety (Brahmbhatt et al., 2020). Besides, the patient has been taking medications for anxiety after a past diagnosis. The patient also finds it hard to manage her racing thoughts and the issue started three years ago. According to DSM-5, a person must experience anxiety consistently for at least six months for a GAD diagnosis (Brahmbhatt et al., 2020). Another criteria of GAD are experiencing sleep disturbance, fatigue, restlessness, irritability, muscle tension, and concentration issues. A.N. reported fatigue, irritability, sleep disturbance, increased heartbeat and breathing when she is anxious. An individual only needs to have three of the signs to meet the criteria. The anxiety is also affecting her functioning especially work.

2. Alcohol Use Disorder (AUD)

The patient is being treated for alcohol use disorder. She reported using at least four drinks every day to manage anxiety for the last one year. Takahashi et al. (2017) noted that an individual with AUD strives to minimize drinking unsuccessfully. A.N. has wanted to stop drinking unsuccessfully that is why she is receiving treatment. She also has alcohol cravings. Moreover, AUD is characterized by failing to meet an obligation because of drinking (Takahashi et al., 2017). A.N. has received a warning from her employer because of missing work due to drinking. She is continuing to drink although she is aware it is affecting her work negatively. A.N. is also drinking even though the alcohol worsens her anxiety. A score of 3 on the cage screening test shows she has clinically significant alcohol problems. The patient has six of the DSM 5 symptoms of AUD diagnosis. Thus, she has severe alcohol use disorder.

3. Panic Disorder

The patient experiences shortness of breath, palpations, and nausea, which are symptoms of panic disorder. However, she does not have panic attacks when she is experiencing the mentioned symptoms. Panic disorder in the DSM 5 is also characterized by persistent worry and abnormal behavioral changes after a panic attack (Kim, 2019). A.N. does not have panic disorder as she has never had a panic attack.

Reflections:

I agree with the preceptor’s diagnosis of severe longstanding alcohol use disorder and generalized anxiety disorder. The patient also has a history of depression, which has been managed through medications. This case showed that co-occurring alcohol use disorder and psychiatric conditions are very complex. The symptoms of alcohol addiction, anxiety, and depression overlap. Besides, some patients use alcohol to self-medicate mental health diseases. For instance, the client in this case started abusing alcohol to manage anxiety and sleep problems. Long-term self-medication with alcohol became an addiction. Untreated anxiety and depression also worsen alcohol use disorder. If I were to repeat the session, I would determine why the patient had received a bipolar 2 disorder diagnosis in the past.

Legal/Ethical Considerations

The patient must understand the risks and benefits of all the medications she receiving for alcohol use disorder and anxiety. Respecting a patient’s autonomy and informed consent are important ethics when offering mental health treatment (Barnett, 2019). Moreover, the patient cannot be hospitalized for alcohol use treatment against her will. If she wants to leave the inpatient treatment program, she can do so anytime. Confidentiality is also relevant, as the PMHNP cannot share private medical information without the client’s consent. However, if she is a danger to herself and others, then the patient’s private medical information can be released. Legal reasons could also override the confidentiality principle. The ethics of beneficence and non-maleficence are crucial to ensure that the medications the PMHNP prescribes do not have adverse side effects on the patient. The patient is taking multiple drugs for her co-occurring conditions; hence, careful monitoring of side effects is necessary. The medications should benefit the patient not harm her.

Health Promotion and Disease Prevention

Comorbid alcohol addiction and anxiety makes this case challenging. The PMHNP must ensure the patient receives adequate treatment for alcohol use disorder, anxiety, and sleep disturbance. Therefore, the PMHNP should recommend non-pharmacological strategies to promote sleep. Another action is to monitor the patient to determine if she really has type 2 bipolar disorder. Managing all the client’s mental health diagnoses will enhance her alcohol addiction recovery. Currently, the patient lives alone, which can hinder her recovery. If possible, the patient should be advised to live with her parents. The parents’ home is nearby and living with them would provide the patient with the necessary social support. The family would monitor her to prevent relapse after treatment for alcohol addiction.

Case Formulation and Treatment Plan: 

The patient has comorbid alcohol use disorder and anxiety. Therefore, she should continue taking BuSpar 15 mg twice a day and the low-dose olanzapine for the anxiety symptoms. I will start her on a trial of doxepin beginning 50 mg at bedtime to manage the lack of sleep. A follow up with her for the next five days is necessary. The patient is also taking Antabuse for alcohol use disorder treatment. I will also start her on Vivitrol soon for the alcohol problems.

Some of the side effects of Antabuse that the patient should know are seizures, confusion, muscle weakness, and numbness. Severe side effects of BuSpar are tardive dyskinesia, tremors, and muscle stiffness. Olanzapine could cause confusion, fainting, numbness, stomach pain, slow heartbeat, urinating problems, and tremors. Vivitrol severe side effects include liver issues, depressive symptoms, coughing, shallow breathing. She should avoid other opioids and illegal substances while on Vivitrol and large amounts of coffee when taking Antabuse. However, the antidepressants would not affect contraceptives though the patient reported being sexually inactive and not using any contraceptive. She should report to the PMHNP if she becomes pregnant. The patient should also avoid mixing the antidepressants with alcohol to prevent drowsiness and sedation.

The treatment plan will also include CBT for both anxiety and alcohol addiction. Coates et al. (2018) mentioned that CBT enables individuals with alcohol use disorder to recognize the negative thoughts and behaviors that promote alcohol use. CBT will also help the patient to manage her racing thoughts to control anxiety. A health promotion activity that the PMHNP recommends for the patient is regular exercise. Notably, exercise increases relaxation and reduces anxiety. Decreased anxiety will also help the patient in alcohol addiction recovery. Beneficial alternative therapies for anxiety management include yoga, balanced diet, and meditation (Brahmbhatt et al., 2020). A patient education strategy that would be useful for this case is including the parents. The family members will support the patient in her recovery journey.

Collaboration with a psychiatrist to determine if the client has type 2 bipolar disorder.

Patient advised to continue with inpatient alcohol treatment program and case management.

Patient advised to visit the ER if she becomes suicidal or homicidal or call 911 if she experiences adverse side effects from the prescribed medications.

Patient was given time to ask questions regarding the treatment plan. She agreed to the prescribed medications and to continue receiving inpatient treatment for alcohol addiction.

Follow up with patient is to be done after five days.

No additional labs ordered for the patient at this point.

References

Barnett, J. E. (2019). The ethical practice of psychotherapy: Clearly within our reach. Psychotherapy, 56(4), 431-440. http://dx.doi.org/10.1037/pst0000272

Brahmbhatt, A., Richardson, L., & Prajapati, S. (2020). Identifying and managing anxiety disorders in primary care. The Journal for Nurse Practitioners, 17(1),18-25. https://doi.org/10.1016/j.nurpra.2020.10.019

Coates, J. M., Gullo, M. J., Feeney, G., Young, R. M., & Connor, J. P. (2018). A randomized trial of personalized cognitive-behavior therapy for alcohol use disorder in a public health clinic. Frontiers in Psychiatry, 9, 297. https://doi.org/10.3389/fpsyt.2018.00297

Kim, Y. K. (2019). Panic disorder: Current research and management approaches. Psychiatry Investigation, 16(1), 1–3. https://doi.org/10.30773/pi.2019.01.08

Takahashi, T., Lapham, G., Chavez, L. J., Lee, A. K., Williams, E. C., Richards, J. E., Greenberg, D., Rubinsky, A., Berger, D., Hawkins, E. J., Merrill, J. O., & Bradley, K. A. (2017). Comparison of DSM-IV and DSM-5 criteria for alcohol use disorders in VA primary care patients with frequent heavy drinking enrolled in a trial. Addiction Science & Clinical Practice, 12(1), 17. https://doi.org/10.1186/s13722-017-0082-0