Week 12 Clinical SOAP Note

Comprehensive Clinical SOAP Note on Mental Health Essay Example

Subjective:

CC: “I am scared of losing my family.”

HPI: PT is a 32-year-old African American male. PT is in for counseling to stop “drinking too much.” “I drink about four bottles daily to keep me going.” His drinking began five months ago after losing his dream job. He is afraid he will lose his house and family, which makes him worried and anxious most of the time. “Sometimes I get angry at my family or myself for no reason and end up destroying things around me,” He reports trouble with sleeping and hallucinates about losing his house. “I drink alcohol to forget, but I cannot. It is like I am losing my mind.” He wants to be sober and find other sources of income but gets to drinking whenever he thinks of not being able to support his family. He reports feeling nauseated and vomiting after drinking. He gets headaches whenever he drinks and talks over-the-counter aspirin to relieve the headache. The patient reports taking Estazolam every day to help him sleep. PT also no longer goes out with friends during the weekend for fear of drinking too much. He feels worthless to his family and has considered taking his life.(Comprehensive Clinical SOAP Note on Mental Health Essay Example)

Past Medical Hx:

• Current Medications: Aspirin 325 mg PO q4hr PRN for headache. Estazolam 1 mg PO HS for insomnia.
• Medication trials: None.
• Psychiatric diagnosis: None.
• Allergies:No known medication, environmental, or food allergies

Family Hx: Married with a daughter aged 5. The daughter is all alive and well. The wife was diagnosed with depression one month ago. Maternal and paternal grandparents are all deceased. Paternal grandfather died of throat cancer. Paternal grandmother died in an accident. Maternal grandfather died of kidney failure. Paternal grandmother died from depression.

Substance Use Hx: Reports abusing alcohol and cannabis.

Personal and Social Hx: Graduate of B.Sc. Economics. Worked as a financial analyst before being laid off. Not interested in politics. No pertinent legal history. Likes adventure and gardening.(Comprehensive Clinical SOAP Note on Mental Health Essay Example)

ROS:

GENERAL: Reports 2 lbs weight loss and fatigue.

HEENT: Reports eye pain. Ears: No hearing loss Nose: No nasal congestion. Throat: No sore throat.

SKIN: Normal skin turgor and pressure. (Comprehensive Clinical SOAP Note on Mental Health Essay Example)

CARDIOVASCULAR: No chest discomfort or palpitations.

RESPIRATORY: No wheezing, cough, or breath pain.

GASTROINTESTINAL: No constipation or abdominal pain.

GENITOURINARY: Reports urinary frequency.

HEMATOLOGIC: No easy bruising or bleeding.

LYMPHATICS: No swollen or enlarged nodes.

NEUROLOGICAL: No focal weakness. Reports headache.

MUSCULOSKELETAL: No muscle or joint pain.

ENDOCRINOLOGIC: No polyuria or polydipsia.

PSYCHOLOGICAL: Reports anxiety. Reports suicide ideation.

Objective:

Vital Signs: Temp: 98.3 F, BP: 112/75, R: 18, HR: 81, O2: 98, Ht: 5’7’’, Wt.: 130 lbs., BMI = 20.4 kg/m², healthy weight.

Diagnostic results:

Tox Screen: Positive for alcohol.

Mental Status Examination: PT is not well-dressed for the occasion and time. He is cooperative. The client appears to be in distress. Abnormal psychomotor activity is noted during the psychiatric assessment. PT avoids eye contact. The effect is blunt with the reported mood of anxiety. Concentration is limited. The speech is not organized but expressive of the situation. Resigned thought pattern. Normal insight and perception. Has normal cognition with difficulty with abstract thought. Memory and judgment are grossly intact. According to today’s exam, the patient has a high risk of suicide ideation, self-harm, or harm to others.(Comprehensive Clinical SOAP Note on Mental Health Essay Example)

Diagnostic Impression:

1. Alcohol use disorder: The client’s symptoms suggest moderate alcohol use disorder (AUD), 303.90 (FI 0.20). The client’s essential features of AUD include problematic alcohol use patterns, often in large amounts, carvings, failure to fulfill routine obligations, and constant use (American Psychiatric Association, 2019).(Comprehensive Clinical SOAP Note on Mental Health Essay Example)
2. Major Depressive Disorder: The client’s symptoms also suggest Major depressive disorder (MDD), 296.23 (F32.2). The client’s essential features of MDD include depressed mood, diminished interest in routine activities, weight loss, insomnia, loss of energy, psychomotor agitation, and worthlessness (APA, 2019). However, the client’s symptoms are best explained by AUD. Therefore, this diagnosis is refuted.(Comprehensive Clinical SOAP Note on Mental Health Essay Example)
3. Cannabis Use Disorder: The client’s symptoms suggest cannabis use disorder (CUD), 296.23 (F32.2). The essential features of CUD include taking cannabis in large amounts, having the desire to control cannabis use, craving for cannabis, and recurrent use (APA, 2019). However, the client’s cannabis use is not recurrent, and there is no strong desire or large consumption. AUD best explains the client’s symptoms. (Comprehensive Clinical SOAP Note on Mental Health Essay Example)

Reflections: The patient’s symptoms strongly suggest AUD. However, what I would have done differently would be to invite the patient’s wife during the assessment. The wife would be at a better positive to provide additional information relating to the client’s behavioral conduct. I will go about this by asking the patient if he is okay with the wife’s presence. Further information from the wife would be crucial in determining whether the client is at significant risk to his family or himself to warrant inpatient treatment and observation.(Comprehensive Clinical SOAP Note on Mental Health Essay Example)

Treatment Plan: 

#99221

Admit the patient as per the mental examination and HPI for seven days. The client is unstable and is a risk to himself and his family due to emotional pain (Betz & Boudreaux, 2016) despite his interest in a better life. The goal of an inpatient admission is to stabilize the patient and prevent suicide.(Comprehensive Clinical SOAP Note on Mental Health Essay Example)

#99204

Discontinue aspirin and Estazolam. Start disulfiram for AUD. The recommended initial dosage is 250mg PO to manage AUD abstinence. The patient must be evaluated daily to monitor and respond to withdrawal symptoms.

#98960

Discuss with the client the impact of alcohol on his health and the potential impact on his family, including violence and divorce. Discuss with the client the adverse effects of over-the-counter medication, including addiction and associated health risks.(Comprehensive Clinical SOAP Note on Mental Health Essay Example)

Refer the patient to a psychiatrist for CBT. CBT is crucial in managing cognitive and behavioral deviations through constructive biofeedback and relaxation mechanisms (Benjamin et al., 2014). The client desires to regain normalcy, and CBT will be crucial in achieving sobriety.(Comprehensive Clinical SOAP Note on Mental Health Essay Example)

Discharge: After seven days.

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7^th ed.). American Psychiatric Publishing, Inc.   (Comprehensive Clinical SOAP Note on Mental Health Essay Example)

Benjamin, J. S., Virginia, A. S., & Pedro, R. (2014). Kaplan & Sadock’s synopsis of psychiatry behavioral sciences/clinical psychiatry (11^th ed.). Wolters Kluwer

Betz, M. E., & Boudreaux, E. D. (2016). Managing suicidal patients in the emergency department. Annals of Emergency Medicine, 67(2), 276-282. https://doi.org/10.1016%2Fj.annemergmed.2015.09.001(Comprehensive Clinical SOAP Note on Mental Health Essay Example)