Comprehensive Psychiatric Soap Note Nursing Paper Sample
Subjective:
CC (chief complaint): “I want to cut my alcohol drinking habit.”
HPI: XX is a 31-year-old male who presented to the office and complained about alcohol addiction. The patient reports excessive drinking as a teenager as he did not want to be bothered by anyone. “I think people did not love me, and I was always by myself. The patient reports being treated for alcohol, anxiety, and depression. The patient last took medication a month ago, including Neurontin 300 mg PO once a day, Prozac 40 mg, and Tegretol 200 mg in the morning and 200 mg at bedtime. The patient reported a history of suicide and once tried to drink himself to death. He went to a program for alcohol once a week. He went to UNDNJ for a few days due to a drinking problem in the ER and has been in the ER for alcohol several times. The patient wants to get back to medication. The patient denies a history of physical or sexual abuse. The patient had his first drink at 16 years old. The patient’s goal is to get better and maintain a healthy lifestyle.(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
Past Psychiatric History: Has a history of depression and anxiety.
General Statement: The patient reported that this is the first time he has sought help. The patient denied seeking help as a teenager. The first time he sought help was a Rutgers in 2015, aged 25.
Caregivers: NA
Hospitalizations: The patient denied being ever hospitalized.
Medication trials: The patient denied any medical problems.
Psychotherapy or Previous Psychiatric Diagnosis: The patient is diagnosed with moderate Major Depressive Disorder (MDD), recurrent General Anxiety Disorder (GAD), and alcohol use disorder (AUD). (Comprehensive Psychiatric Soap Note Nursing Paper Sample)
Substance Use History: The patient denied any other substance abuse
Family Psychiatric/Substance Use History: Father suffers from PTSD and anxiety, the mother has depression and anxiety, and the brother has depression, anxiety, and alcohol.
Social History: The patient was born and raised in Newark, NJ, by his mother. He is the oldest of four children. The patient started a relationship six months ago. (Comprehensive Psychiatric Soap Note Nursing Paper Sample)
Educational Level: He’s a high school graduate.
Hobbies: He’s been working for six months now.
Work History: He worked at McDonald’s, hotel, and car services, and now he’s working as a concierge.
Legal history: The patient denied any history of criminal activities.
Trauma history: Any childhood or adult history of trauma?
Violence Hx: No violent concern or safety issues.
Medical History:
Current Medications: No current medications.
Allergies: None reported.
Reproductive Hx: NA
ROS:
GENERAL: No fatigue, weight loss, fever, or chills.
HEENT: No headache. Eyes: No double vision. Ears: No hearing loss. Nose: No breathing difficulty. No nasal congestion. Throat: No sore throat.(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
SKIN: No skin rashes or itches.
CARDIOVASCULAR: No chest pain/pressure, edema, or palpitations.
RESPIRATORY: No difficulty with breath, wheeze, or cough.
GASTROINTESTINAL: No abdominal discomfort.
GENITOURINARY: Not pregnant. No hematuria or dysurias.
NEUROLOGICAL: No seizures, extreme tingling, or hallucinations. MUSCULOSKELETAL: No joint swelling, pain, or stiffness.
HEMATOLOGIC: No hemophilia.
LYMPHATICS: No enlarged nodes.
ENDOCRINOLOGIC: No hypothyroidism.
Objective:
Temp: 98 F, BP: 125/83, HR: 82, R: 18, O2: 97.8, Ht: 5’9’’, Wt: 160lbs, BMI: 23.6 kg/m2
Diagnostic results:
Tox screen: Abnormal (Positive for alcohol)
Relevant Screening Tools:
- Columbia Suicide Severity Rating Scale (C-SSRS): A score of 3 indicates active suicide ideation. C-SSRS is effective for screening suicide risks (Salvi, 2019).(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
- Patient Health Questionnaire (PHQ-9): A score of 19 indicates moderately severe depression. PHQ-9 is reliable for screening depression severity and suicide risks (Rossom et al., 2017; Sun et al., 2020)
Assessment:
Mental Status Examination: The patient is a 31-year-old male who looks his age. He is alert and oriented. He is well-kempt. He appears to be in acute distress. He is calm and interactive. His language is daily. He is upbeat with a broad and expansive emotional range. Thought form and content are future-oriented with a normal ability to abstract. The patient is cognitively intact. His recent memories are intact. Has active suicide ideation. The patient is assessed to be at risk of self-harm.
Diagnostic Diagnosis: The patient’s symptoms meet the criteria for severe Alcohol Use Disorder (AUD), moderate Major Depressive Disorder (MDD), and recurrent Generalized Anxiety Disorder (GAD).(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
- Alcohol Use Disorder (AUD) – AUD is determined by characteristic alcohol use and a significant amount/period of alcohol abuse, extended time spent obtaining alcohol, craving for alcohol, or withdrawal over 12 months (American Psychiatric Association [APA], 2019). The patient reports starting alcohol aged 16, and at 31, he is still drinking. He also reports drinking excessively. He wants to cut down his drinking, but he is unable. Heavy and problematic alcohol use is considered a significant risk factor for alcohol use disorder in the USA (Kranzler & Soyka, 2018). The patient’s goal is to get better and maintain a healthy lifestyle free from alcohol abuse. Therefore, this is the primary diagnosis.(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
- Avoidant Personality Disorder (AVPD) – chronic feelings of social inadequacy characterize AVPD. The diagnostic features of APD include persistent social inhibition and hypersensitivity to negative judgments (APA, 2019). AVPD starts at an early age and has a lifelong impact on affected individuals (Lampe & Malhi, 2018). In this case, the patient did not want to be bothered by anyone as a teenager. He felt that nobody loved him and was always by himself, which could mean preoccupation with other people’s judgment. He did not seek help for his drinking problem and only sought help for the first time in 2015. However, the client does not report avoidance of occupational roles and unwillingness to get involved with others which are significant features of AVPD diagnosis. Besides, he reports starting a relationship six months ago. Therefore, this diagnosis is refuted.(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
- Moderate Major Depressive Disorder (MDD) – The criteria for MDD diagnosis include depressed moor of pleasure presenting for two weeks. Insomnia, fatigue, weight loss, and recurrent suicide ideation are common with MDD (APA, 2019). The client reports being distant as a child, and this is the first time he is seeking help. Social isolation/loneliness is associated with depression in young people (Achterbergh et al., 2020). However, this diagnosis is refuted since the client does not report other significant MDD symptoms outlined in the DSM5.(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
- Recurrent Generalized Anxiety Disorder (GAD) – GAD is characterized by anxiety and worries out of proportion on most days for six months or more. Difficulty controlling worry, restlessness, fatigue, difficulty concentrating, irritability, sleep disturbance, and muscle tension (APA, 2019). The patient is concerned with his drinking habit and potentially reaching a point of drinking himself to death and needs help. Individuals with GAD often feel on edge and helplessly tend to seek help for their anxiety (Munir et al., 2022). However, the patient does not present most of the GAD symptoms. Therefore, this diagnosis is refuted.(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
Reflections
I agree with the preceptor’s assessment and diagnostic impression of the patient. The client’s symptoms are characteristics of AUD, AVPD, MDD, and GAD. However, the patient’s symptoms are better explained by AUD as the primary diagnosis. The potential social determinant of health relevant to the client’s alcohol abuse is education level/literacy, healthy behaviors, social support, and coping skills. A lower education level is associated with higher alcohol consumption (Schmengler et al., 2022), which explains the client’s alcohol abuse as a teenager. Besides, a lack of social support and coping skills causes pathologic alcohol consumption (Moon et al., 2022). Lastly, factors such as advertisements and marketing of alcohol products and consequent ease of access in a person’s neighborhood can lead to alcohol abuse as a teenager and result in addiction in later life (Sudhinaraset et al., 2016). The patient’s goal is to get better and maintain a healthy lifestyle.(Comprehensive Psychiatric Soap Note Nursing Paper Sample)
Conclusion
As a mental health care specialist, the patient should be advised on available community resources or alcohol for alcohol addiction, the need for social interactions, routine exercise, and suicide emergency care. Moreover, the patient needs to risks associated with AUD and the need for intervention.
References
Achterbergh, L., Pitman, A., Birken, M., Pearce, E., Sno, H., & Johnson, S. (2020). The experience of loneliness among young people with depression: a qualitative meta-synthesis of the literature. BMC Psychiatry, 20(1), 1-23. https://doi.org/10.1186/s12888-020-02818-3
American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc. (Comprehensive Psychiatric Soap Note Nursing Paper Sample)
Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. Jama, 320(8), 815-824. https://doi.org/10.1001%2Fjama.2018.11406
Munir, S., Takov, V., & Coletti, V. A. (2022). Generalized anxiety disorder (nursing). In StatPearls [Internet]. StatPearls Publishing. (Comprehensive Psychiatric Soap Note Nursing Paper Sample) https://www.ncbi.nlm.nih.gov/books/NBK441870/
Rossom, R. C., Coleman, K. J., Ahmedani, B. K., Beck, A., Johnson, E., Oliver, M., & Simon, G. E. (2017). Suicidal ideation reported on the PHQ9 and the risk of suicidal behavior across age groups. Journal of Affective Disorders, 215, 77-84. (Comprehensive Psychiatric Soap Note Nursing Paper Sample) https://doi.org/10.1016%2Fj.jad.2017.03.037
Salvi, J. (2019). Columbia-Suicide Severity Rating Scale (C-SSRS). Emergency Medicine Practice, 21(5), CD3. (Comprehensive Psychiatric Soap Note Nursing Paper Sample) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7974826/
Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospitals. BMC Psychiatry, 20(1), 1-7(Comprehensive Psychiatric Soap Note Nursing Paper Sample) . https://doi.org/10.1186/s12888-020-02885-6
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