Care Across the Lifespan I

Comprehensive Focused SOAP Psychiatric

Comprehensive Focused SOAP Psychiatric

Subjective:

CC (chief complaint): “I have a history of taking medications and then stopping them. I don’t think I need them. I feel like the medication squashes, which I am.”

HPI: Individual is a 27-year-old female who has presented to the clinic for a mental health assessment. She complains that she has a history of discontinuing her medication since they interfere with who she is. She has been hospitalized in the past due to insomnia and auditory hallucinations. In total, she has been hospitalized four times for mental health disorders. One of the hospitalizations was for a suicidal attempt when she overdosed on Benadryl. She reports she has had past diagnoses of depression and anxiety. She reports being treated with Zoloft in both instances, which made her feel high. She also reports being medicated with risperidone and Seroquel, which she reports made her gain weight and Klonopin, which she reports made her slow. She reports her mother had bipolar disorder and her father had substance abuse disorder. She suspects that her brother has schizophrenia. No family history of suicide.

Substance Current Use: Smokes a pack of cigarettes daily

Medical History:

· Current Medications: Medication for hypothyroidism and birth control pills for polycystic ovaries

· Allergies: No reported allergies

· Reproductive Hx: Regular menstrual cycles and the patient is sexually active.

ROS:

· GENERAL: Alert and oriented to person, time, and place. There is no acute distress, and the patient looks well nourished.

· HEENT: The patient’s skull is atraumatic and normocephalic. Vision is clear, absent of any blurriness. She does not report any headaches, and there are no inflammations in her throat, ears, or nose.

· SKIN: The skin is intact with no breakages or bruises and sufficiently moist.

· CARDIOVASCULAR: there is no tightness in the chest, and then he has a regular heart rate.

· RESPIRATORY: No breathing difficulties or coughing noted.

· GASTROINTESTINAL: Bowel movement is normal; there is no constipation or diarrhea. The patient does not report any nausea or vomiting, and the abdomen is not tender upon palpation.

· GENITOURINARY: Normal urinary patterns without any incontinence. There are no burning sensations or discomforts when passing urine. There is no vaginal discharge or urinary tract infections.

· NEUROLOGICAL: Cranial nerves are in place and intact, and there is no nuchal rigidity.

· MUSCULOSKELETAL: The patient’s lower and uindividial er extremities are normal, and his movements are within a typical range. The patient also has a normal gait.

· HEMATOLOGIC: There are no bleeding or anemic issues.

· LYMPHATICS: Lymph nodes are normal without any inflammations.

· ENDOCRINOLOGIC: The patient has a hormonal imbalance causing hypothyroidism, indicative of low thyroid hormone levels and high TSH.

Objective:

Diagnostic results: The patient’s vital signs are within normal range. Laboratory tests for drug and alcohol screening returned negative results. CBC and CMP are all within normal range. There are low levels of FT$ thyroid hormones and high levels of TSH.

Assessment:

Mental Status Examination: the patient is very cooperative during the mental status examination. She is well oriented to time, place, and person. Her speech is normal in articulation, volume, and rate. It is also coherent and spontaneous. Her attitude and body posture reveal an underlying depressive state. This is also the case with her general demeanor and facial expression. Her affect is congruent with her mood, full range, and aindividial ropriate. There are no indicators of psychotic process, bizarre behaviors, delusions, or aindividial arent signs of hallucinations. Her associations are all intact, the content is aindividial ropriate, and her thought and thinking are logical. While she has been suicidal in the past, currently, suicidal ideation and homicidal intentions are comprehensively denied. Fund of knowledge and cognitive thought is aindividial ropriate for the patient’s age. Her judgment is fair, and there are no indications of anxiety.

Diagnostic Impression:

Major Depressive Disorder

Major depressive disorder is a common mental health condition where the affected has an overwhelming and chronic feeling of sadness, emptiness, or the inability to find pleasure in activities that would otherwise pleasure them *. Some of the symptoms of major depressive disorder are a depressed mood for the better part of the day; this may be indicated by the subjected or observed by others (APA, 2013). Another symptom is a lack of pleasure or interest in almost all activities that would pleasure the subject (APA, 2013). Another symptom of major depressive disorder is considerable weight gain or weight loss (APA, 2013). This is the primary diagnosis because the patient’s symptoms fit the diagnostic criteria. The patient also has a history of depression, having been hospitalized on different occasions. The patient also reports experiencing auditory hallucinations. While this is not common in major depressive disorder, studies show that in some cases, patients can hear voices from time to time (Zhuo et al., 2020).

Mood Disorder Due To Another Medical Condition

According to APA (2013), mood disorders can also result from other medical conditions. A diagnosis of major depressive disorder should only be arrived at if the mood disturbances are not based on laboratory findings, physical examination, history, or a pathophysiological consequence of a condition such as hypothyroidism). In this case, the patient also has hypothyroidism which can lead to depressed moods, weight gain, exhaustion, and slow movements and thought processes (Duntas & Yen, 2019). Studies show that hypothyroidism can lead to changes in the affected individual’s mood, leading to depression or anxiety (Duntas & Yen, 2019). However, this diagnosis is ruled out because hypothyroidism cannot cause auditory hallucinations, and the patient had had similar symptoms in the past when she had MDD.

Schizophrenia

This is a mental disorder where the affected has a warped interpretation of reality. The will often experience delusions and hallucinations (McCutcheon et al., 2020). In some cases, the will also present with extremely disorganized behavior and thinking, which can be disabling (McCutcheon et al., 2020). Schizophrenia is considered a possible diagnosis in this case because the patient reports hearing voices which qualify as an auditory hallucination. However, it is ruled out because the auditory hallucinations are not intense enough to meet the criteria for a diagnosis of schizophrenia. In addition, many other symptoms the patient is experiencing are not consistent with schizophrenia.

Bopolar disorder

(due to manic behaviour)

Reflections:

She reports being treated with Zoloft in both instances, which made her feel high. She also reports being medicated with risperidone and Seroquel, which she reports made her gain weight and Klonopin, which she reports made her slow

Individual has been diagnosed with MDD, and she is also under treatment for hypothyroidism. She must continue treating the hypothyroidism even as she begins treatment for the MDD. She also seems to be engaging in risky sexual behavior, so it is vital to conduct patient education.

Case Formulation and Treatment Plan: 

INDIVIDIAL has been on several medications for MDD, and she discontinues them for various reasons. referred for intensive counseling services.It is important to start her on Citalopram 20mg daily to stabilize her moods. The medication can be slowly titrated upwards while monitoring her reaction to it to minimize the chances of discontinuing it. She should finish the dose of the medication she was given to treat hypothyroidism. She should be scheduled for a follow-up aindividial ointment in one week to assess her progress.

References

American Psychiatric Association. (2013).  Diagnostic And Statistical Manual of Mental

Disorders. https://doi.org/10.1176/aindividial i.books.9780890425787

Duntas, L. H., & Yen, P. M. (2019, October 1). Diagnosis and treatment of

hypothyroidism in the elderly. Endocrine, Vol. 66, individial . 63–69.

https://doi.org/10.1007/s12020-019-02067-9

McCutcheon, R. A., Marques, T. R., & Howes, O. D. (2020). Schizophrenia—an

overview.  JAMA psychiatry,  77(2), 201-210. 10.1001/jamapsychiatry.2019.3360

Zhuo, C., Xu, X., Lin, X., Chen, M., Ji, F., Jiang, D., ... & Zhou, C. (2020). Depressive

symptoms combined with auditory hallucinations are accompanied with severe gray matter brain impairments in patients with first-episode untreated https://doi.org/10.1016/j.neulet.2020.135033

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