SOAP NOTE ON DEPRESSION

Patient V.S is a 27-year-old Hispanic male who presented to the office for follow up treatment because has been discharge form a hospital.  He was admitted due being depressed.  He was positive for alcohol, cannabis, amphetamine, benzodiazepine.  His blood alcohol level was 154.  Patient reported drinking 6 packs of beer of 24 oz beer every weekend.  Patient has no history of seizure, delirium treatments.  He smokes marijuana daily, first use in 2010.  He’s been using Cocaine since the age of 15.  History of intranasal opioid use.(Comprehensive Soap Note Essay Example on Depression)

·      Depressant, Benzodiazepine, 3 tabs daily for 3 years.

·      3 mg of Xanax

·      Oxycodone 5 tabs daily for about a month

·      Percocet 10 mg

·      Cannabis 2 joint

·      1 pack of cigarette daily

Past medical history of pancreatitis (resolved)

History of ADHD, ODD, alcohol disorder, stimulant use disorder, Cannabis use disorder and Bipolar 1 disorder.  Patient has history of 13 inpatient psych admissions(Comprehensive Soap Note Essay Example on Depression)

Patient is on Zoloft, Vyvanse, Abilify, Lithium, Clonazepam, Bupropion

Patient has history of DUI

Patient’s father has a restraining order against him.

Patient denied being incarcerated. 

Family history: mother died 2 years ago from pancreatic cancer.

Father has history of high cholesterol and hypertension.

Patient has 2 other siblings. 

Patient is unemployed and patient is homeless, 

Education: patient dropped out high in 10th grade

Objective data:

BP 124/83

Pulse 89

Temperature 97.9 F

Respiration 18

Oxygen is 98% on room air.

CIWA 0 at the time of evaluation:

Protective factor: patient is afraid of dying.

Comprehensive Soap Note Essay Example on Depression–Complete Psychiatric Evaluation

CC (chief complaint): “I am here for a follow-up treatment.”

HPI: V.S is a 27-year-old Hispanic male who presented to the office for follow-up treatment. He had been discharged from the hospital following admission due to depression. V.S has a history of opioid, alcohol, marijuana, and cocaine abuse. He reports drinking six packs of 24 oz beer every weekend. He has smoked marijuana daily since 2010 and has been using cocaine since age 15. He reports intranasal opioid use. He reports a history of pancreatitis resolved through medication. The patient denies a history of seizures or delirium treatments. He reports being afraid of dying.(Comprehensive Soap Note Essay Example on Depression)

Past Psychiatric History:

• General Statement: This is the 14^th time the patient is seeking treatment.
• Caregivers (if applicable): N.A.
• Hospitalizations: The patient has a history of 13 inpatient psych admissions
• Medication trials: None reported(Comprehensive Soap Note Essay Example on Depression)
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has no history of seizure or delirium treatments.

Substance Current Use and History: Reports drinking beer, smoking marijuana, and using cocaine.

• Depressant, Benzodiazepine, 3 tabs daily for 3 years.
• 3 mg of Xanax
• Oxycodone 5 tabs daily for about a month
• Percocet 10 mg
• Cannabis 2 joint
• 1 pack of cigarettes daily

Family Psychiatric/Substance Use History: History of ADHD, ODD, alcohol disorder, stimulant use disorder, Cannabis use disorder, and Bipolar 1 disorder. (Comprehensive Soap Note Essay Example on Depression)

Psychosocial History: Father has a history of high cholesterol and hypertension. Mother died 2 years ago from pancreatic cancer. The patient has 2 other siblings.(Comprehensive Soap Note Essay Example on Depression)

Occupational History: The patient is unemployed, and the patient is homeless, 

Education history: The patient dropped out of high school in the 10^th grade

Legal history: The patient has a history of DUI. The patient denied being incarcerated. The patient’s father has a restraining order against him.(Comprehensive Soap Note Essay Example on Depression)

Medical History:

• Current Medications: Zoloft, Abilify, Lithium, Clonazepam, Bupropion
• Allergies: Not reported.
• Reproductive Hx: Not reported.

ROS:

GENERAL: No weight loss, fever, weakness, or fatigue.

HEENT: Eyes: No visual loss. Ears, Nose, Throat: No hearing loss, nasal congestion, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, pressure, or discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or phlegm.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: No painful urination. No urination urgency or hesitancy.

NEUROLOGICAL: No headache, dizziness, or tingling in the extremities.

MUSCULOSKELETAL: No muscle, back, or joint pain.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes or history of splenectomy.

ENDOCRINOLOGIC: No reports of heat, sweat, or cold intolerance. No polyuria or polydipsia.

Physical exam: N.A.

Diagnostic results:

Vital Signs: BP 124/83, Pulse 89, Temperature 97.9 F, Respiration 18, Oxygen is 98% on room air.

Labs: BAC: 154mg/dL

Urine: +THC, +AMT, +BZD

CIWA: 0 at the time of evaluation

Assessment

Mental Status Examination:  V.S is alert and oriented in all spheres. He is inappropriately dressed. Appears to be in acute distress. He is calm, interactive, and makes fair eye contact. His state mood, “normal,” is not congruent with affect. The emotional range is expansive in intensity. Thought form and content are scattered. The patient experienced attention and concentration difficulties during the psychiatric evaluation. Insight is poor with normal general perception. Cognition/memory are above average. However, the patient experienced difficulty with abstract thought. Judgment is poor. The patient denies current suicide or homicide ideation. The patient is presently assessed to be at a lower risk of self-harm or harm to others.(Comprehensive Soap Note Essay Example on Depression)

Differential Diagnoses:

1. Alcohol Use Disorder – The patient’s subjective data suggests Alcohol Use Disorder (AUD). AUD is characterized by problematic alcohol use within 12 months, resulting in distress and clinical impairment. Diagnosed individuals often consume large amounts of alcohol, have a persistent desire to consume alcohol, craving for alcohol, tolerance for alcohol abuse, and continue alcohol abuse despite knowledge of health outcomes (American Psychiatric Association [APA], 2019). Moreover, affected individuals experience impaired social, occupational, and interpersonal life. In this case, the client reports consuming 6 packs of 24 oz beer every weekend, and his blood alcohol level at the time of evaluation is 154mg/dL. Therefore, this is the primary diagnosis.(Comprehensive Soap Note Essay Example on Depression)
2. Opioid Use Disorder – The patient’s symptoms suggest Opioid Use Diorse (OUD). OUD is characterized by a characteristic pattern of opioid use within a 12-month period that results in distress and clinical impairment. OUD is manifested by the extensive use of opioids, relentless desire to use opioids, spending time seeking to abuse opioids, craving for opioids, and continued opioid abuse despite understanding its impact on health. Affected individuals experience impaired social, occupational, and interpersonal impairment. In this case, the patient reports intranasal opioid abuse. He reports abusing Oxycodone five tabs for about a month and Percocet 10mg, which are strong opioids. Although the patient has a history of intranasal opioid abuse, there is no indication that the client has abused opioids for about 12 months.(Comprehensive Soap Note Essay Example on Depression)
3. Stimulant Use Disorder – The patient presents mild cocaine use disorder symptoms. Stimulant use disorder with cocaine is characterized by a problematic pattern of cocaine use over a 12-month period that results in distress and clinical impairments. Stimulant use disorder with cocaine is manifested by large amounts of cocaine use, craving for cocaine, persistent desire to abuse cocaine, recurrent cocaine use despite knowledge of the impact on health and persistent health issues, and cocaine tolerance (APA, 2019). Affected individuals have impaired social, occupational, and interpersonal activities. In this case, the patient reports using cocaine since he was 15, which shows persistent use.(Comprehensive Soap Note Essay Example on Depression)
4. Tobacco Use Disorder – The patient’s subjective data suggests Tobacco Use Disorder (TUD). TUD is characterized by a pattern of tobacco use over twelve months that results in distress and clinical impairment. TUD manifests in large amounts of tobacco use, persistent desire to use tobacco, craving for tobacco, much time spent seeking to abuse tobacco, continued tobacco use despite knowledge of health impacts or persistent health problems, and tobacco tolerance (APA, 2022). In this case, the patient smokes one pack of cigarettes daily, which indicates more time spend smoking and seeking to smoke.(Comprehensive Soap Note Essay Example on Depression)

Reflections:

I agree with the preceptor that the primary diagnosis, in this case, is alcohol use disorder. Individuals with AUD find it hard to cease alcohol abuse and will always find ways to abuse alcohol. The patient reports drinking 6 pack of 24 oz beer every weekend, and with 24 oz beer can equivalent to two beers, the patient subjectively consumes about 12 beers weekly. Although heavy drinking among men is defined as 15 drinks or more per week, the consistency in the client’s drinking supports AUD as the primary diagnosis. Furthermore, during the evaluation, the client’s blood alcohol level was 154mg/dL, which is the level at which an individual appears drunk and has visual impairment (Dasgupta, 2017).(Comprehensive Soap Note Essay Example on Depression)

Through the case, I learned that AUD and drug abuse are common among homeless people (one in every three) (Mosel, 2022). Significantly, individuals with AUD and other drugs/substance abuse experience high death anxiety and depression, which co-occur with other psychiatric disorders (McHugh & Weiss, 2019). However, it is difficult to make a definitive diagnosis for individuals with comorbid alcohol and drug abuse. Given a similar case, I would administer diagnostic tools to make a comprehensive diagnosis. Moreover, it is ideal for providing patient education on the impact of alcohol and drug abuse on health and recommending relevant community and social service centers for further support in accommodation, healthcare services, and food.(Comprehensive Soap Note Essay Example on Depression)

Conclusion

The patient, in this case, presents symptoms that primarily suggest AUD. However, the patient could be diagnosed with other substance use disorders, including cocaine, opioid, and tobacco, as evidenced by the subjective and objective data. Therefore, further diagnostic tests are necessary to rule out other psychiatric disorders. When dealing with a homeless mental health patient, further recommendations on social services, including accommodation, healthcare services, and food, are critical.(Comprehensive Soap Note Essay Example on Depression)

References

American Psychiatric Association (APA). (2019). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing(Comprehensive Soap Note Essay Example on Depression)

Dasgupta, A. (2017). Alcohol, drugs, genes, and the clinical laboratory. Science Direct.

McHugh, R. K., & Weiss, R. D. (2019). Alcohol use disorder and depressive disorders. Alcohol Research: Current Reviews, 40(1). https://doi.org/10.35946/arcr.v40.1.01(Comprehensive Soap Note Essay Example on Depression)

Mosel, S. (September 2022). Substance Abuse & Homelessness: Statistics & Rehab Treatment. Available at: https://americanaddictioncenters.org/rehab-guide/homeless (Accessed 23 October 2022)