Clinical Soap Note Comprehensive Nursing Essay Example
Client ID: Initials: TY,AGE: 14, Demographic: Caucasian, Gender: F
Subjective.
Chief complaint: The client is checked in a psychiatric emergency room reassessment with a concern of “attempting suicide.” The client mentions that “I just want to die.”(Clinical Soap Note Comprehensive Nursing Essay Example)
Source of reliability: Parents and client. Information is reliable.
Present Illness: The client checks in a psychiatry emergency room in her parents’ company with a concern of attempted suicide. The mother reports that TY has “appeared depressed since childhood.” TY is constantly anxious about life, whether he is loved, and has become argumentative with the parents in the past year. Today, TY attempted to throw himself from the third-floor balcony of their house before being rescued by his father following an argument with the mother over his school performance. TY feels he is the “black sheep” of the family. “My siblings are more loved and excel in everything they do, yet loved playing basketball, which I no longer enjoy. I feel hopeless and helpless, and sometimes I get muscle tension, headaches, and stomachaches. I have always performed “poorly” academically, and I think I can do nothing to change that because I have no pleasure in school anymore. And, my parents are not proud of me”. TY finds it difficult to concentrate in class. The father reports that TY has involved herself in self-destructive activities, including alcohol abuse and cutting her legs when hurting. TY reports sleeplessness, hearing strange sounds telling her to “take her life” by throwing herself down from the balcony. She says, “I don’t fear death, and I have several ways to do it. My only worry is what my parents will feel about it”. Sometimes, TY is cheerful when in the company of her friend “with the same thoughts”.(Clinical Soap Note Comprehensive Nursing Essay Example)
Current psych meds: Mirtazapine 7.5 mg QD BID for depression and anxiety.
Past psychiatric history: Diagnosed with generalized anxiety disorder four years ago.
Past Medical Hx: No endocrine, cardiac, neurologic, or respiratory issues. No history of surgery or chronic problems.
Allergies: Dust allergy.(Clinical SOAP Note Comprehensive Nursing Essay Example)
Substance use/abuse: History of binge drinking. No ETOH or narcotic drugs.
Past family, social history: Third born is a family of six. Has three brothers and a younger sister. Siblings are alive and well. Had relatively normal childhood development. Christian upbringing.
Family psych hx: An aunt was diagnosed with MDD and later committed suicide.
Education/Employment/Disability: 5th grade. No employment history. No disability. (Clinical Soap Note Comprehensive Nursing Essay Example)
Primary support system: Parents.
Hobbies: Basketball.
Review of systems:
Constitutional: No fever or weight loss.
Eyes: Normal vision.
ENT: Hearing and sense of smell intact. No sore throat.
Cardiac: No chest pains.
Respiratory: No cough or wheeze. Denies dyspnea.
GI: No abdominal pain.
GU: Dysuria or Hematuria
Musculoskeletal: No joint pain or swelling.
Skin: No rash, itchiness, or abrasions.
Neurologic: No seizures, numbness, or blackout.
Endocrine: No polydipsia or polyuria.
Reproductive: Sexually active. Last period 9/23/2021. No pregnancies, abortions, or miscarriages.
Objective:
Vitals: BP: 119/75 T: 98.6F, P: 85, R: 18, Ht: 5”0” Wt: 110lbs BMI: 21.5 Kg/m2
Testing:
UDS: Negative.
Alcohol: Positive
Physical Exam:
MSE:
Appearance and Behavior: Well kempt for her age and occasion. The client is withdrawn, limited interaction, and exhibits acute distress. The client does not maintain appropriate eye contact. (Clinical SOAP Note Comprehensive Nursing Essay Example)
Motor Activity: Normal motor activity. Presence of tics was noted, including jitteriness and restlessness.
Speech: Fluent and decreased speech. Sounds anxious and timid.
Mood/Affect: Describes mood as “sad”. Appears dysphoric.Mood and affect congruent.
Thought Content and Process: Delusional about death – suicide/homicide ideation consistent.
Perceptual Disturbances: Depersonalized with negative comments were noted.
Cognition:
Orientation: Alert and oriented × 3.
Concentration: Difficulty maintaining attention and concentration.
Memory: Grossly intact.
Abstract Reasoning: Difficulty with abstract thought.
Insight and Judgement: Fair judgment and insight.
Formulation:
Patient has a history of depression and anxiety. An aunt was diagnosed with MDD and committed suicide. Stressors include poor school performance, sibling rivalry, and interpersonal relationships. The patient is stable but is at acute risk of self-harm or suicide. (Clinical SOAP Note Comprehensive Nursing Essay Example)
DSM5 Diagnoses:
- Major Depressive Disorder (F33.2). MDD is characterized by depressed mood, diminished pleasure in activities, insomnia, psychomotor agitation, fatigue, worthlessness, inability to think or concentrate, and recurrent thought of death (APA, 2013; Sadock et al., 2015). The client presents symptoms that meet the MDD diagnostic criteria, including sadness, homeliness, worthlessness, diminished pleasure in school and playing basketball, sleeplessness, fatigue, and inability to concentrate in school. Besides, the client has significant suicidal thoughts and has attempted suicide. These symptoms have caused the client clinically significant distress and impairment of social and educational functioning. This is the primary diagnosis.(Clinical SOAP Note Comprehensive Nursing Essay Example)
- Generalized Anxiety Disorder (F41.1). GAD is characterized by excessive worry/anxiety and difficulty controlling worry associated with muscle tension, fatigue, restlessness, sleep disturbance, and difficulty concentrating (APA, 2013; Sadock et al., 2015). The client presents similar symptoms characterized by the apprehensive expectation of school examination, muscle tension, irritability, restlessness, and sleeplessness that affect social and educational aspects of her life. MDD better explains the disturbances. This diagnosis is refuted.(Clinical SOAP Note Comprehensive Nursing Essay Example)
- Oppositional Defiant Disorder (F91.3). ODD is characterized by irritable mood or argumentative behavior with resentment, anger, and spitefulness (APA, 2013). The client presents similar symptoms, including an argument with the parents and distress associated with individuals in her social context, including home and school. However, the patient’s symptoms are better explained by MDD. This diagnosis is refuted.(Clinical SOAP Note Comprehensive Nursing Essay Example)
- Persistent Depressive Disorder (F34.1). PDD is characterized by a depressed mood with low self-esteem, insomnia, hopelessness, or fatigue present for one year or more (APA, 2013). Besides, PDD symptoms are not better explained by schizophrenia, schizoaffective disorder, delusional disorder, or substance abuse, which causes clinically significant symptoms that affect social, educational, or occupational functions. The patient presents symptoms of depressed mood, characterized by sleeplessness, hopelessness, low self-esteem, and fatigue. However, this diagnosis is refuted.
- Disruptive Mood Dysregulation Disorder (F34.8). DMDD is characterized by verbally inconsistent temper outbursts and severe irritability (APA, 2013). The client consistently argues with the parents and becomes irritable and angry. However, these symptoms should be observed in a child before the age of 10. This diagnosis is refuted.(Clinical SOAP Note Comprehensive Nursing Essay Example)
Plan:
Treatment Goals
- Ensure safety of TY. Establish a close monitoring regime; keep her bedroom door open always and keep her company.
- Establish a no-self-harm home plan. Remove every items, such as gun or knives that TY can use to harm herself from the home, search and remove from TY’s room any item that can be used for self-harm, including alcohol and over the counter medication.(Clinical SOAP Note Comprehensive Nursing Essay Example)
- Learn and apply coping skills such as relaxation in functional areas of life, including school and home activities.
- Lear about MDD etiology and stimuli/triggers and how to respond to the associated anxiety and depressive episodes outside of therapy.(Clinical SOAP Note Comprehensive Nursing Essay Example)
Treatment Plan
Pharmacologic:
Start 10mg PO QD HS for 30 days for anxiety. Escitalopram is an FDA-approved and recommended medication for pediatric anxiety and depression. Escitalopram is safe, well-tolerated, and significantly reduces anxiety and depressive symptoms, leading to magnitude social and behavioral improvements (Strawn et al., 2020; Kirino, 2012). (Clinical SOAP Note Comprehensive Nursing Essay Example)
Non-Pharmacologic:
Admit the client for five days to allow close monitoring. The client has a history of self-harm and suicide attempt. In-patient setting provides a safe environment and close monitoring by nurse practitioners, further assessments, immediate response, and treatment recommendations. An in-patient setting facilitates advanced care continuity and allows healthcare practitioners to establish appropriate follow-up (Asarnow et al., 2017).(Clinical SOAP Note Comprehensive Nursing Essay Example)
Start individual and family therapy. Integrated intervention is recommended for MDD and anxiety disorders (Johnson & Vanderhoef, 2016). Individual therapy, such as CBT, allows individuals to identify stressors, learn, and apply coping skills to mitigate symptoms. Family therapy allows parents to contribute to their child’s treatment and wellbeing.(Clinical SOAP Note Comprehensive Nursing Essay Example)
Education:
Educate the parents about the client’s diagnosis, an appropriate response to the client’s depressive and anxiety episodes, benefits, and risks associated with the treatment plan.
Referrals:
Refer to an immediate psychiatrist for further assessment of triggers and suicidal risks. A psychiatrist will have to assess the client’s risk of self-harm and suicide.(Clinical SOAP Note Comprehensive Nursing Essay Example)
Follow-Up:
Return to the clinic after two weeks of discharge for further assessments and recommendation.
References
Asarnow, J. R., Babeva, K., & Horstmann, E. (2017). The emergency department: challenges and opportunities for suicide prevention. Child and Adolescent Psychiatric Clinics, 26(4), 771-783. https://doi.org/10.1016/j.chc.2017.05.002
Strawn, J. R., Mills, J. A., Schroeder, H., Mossman, S. A., Varney, S. T., Ramsey, L. B., … & DelBello, M. P. (2020). Escitalopram in adolescents with generalized anxiety disorder: a double-blind, randomized, placebo-controlled study. The Journal of Clinical Psychiatry, 81(5), 0-0. https://doi.org/10.4088/jcp.20m13396
Kirino, E. (2012). Escitalopram for the management of major depressive disorder: a review of its efficacy, safety, and patient acceptability. Patient Preference and Adherence, 6, 853. https://dx.doi.org/10.2147%2FPPA.S22495
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). London, England: Lippincott Williams, and Wilkins.
Johnson, K. & Vanderhoef, D. (2016). Psychiatric-mental health nurse practitioner review & resource manual (4th ed.). Silver Spring, MD: American Nurses Credentialing.
Write From Scratch