Clinical SOAP Note

Comprehensive Soap Note Example Essay on Mental Health

Subjective:

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

HPI: RY is a 43-year-old African American male. RY is in for counseling to stop “drinking too much.” “I drink about four bottles daily to keep me going.” RY’s drinking began five months ago after losing his dream job. “I feel worthless. I cannot feed my family”. RY 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,” RY reports troubles with sleeping and hallucinates about losing his house. I drink alcohol to forget, but I cannot. It is like I am losing my mind.” RY wants to be sober and find other sources of income but gets to drinking whenever he thinks of him not being able to support his family now. He reports feeling nauseated and vomiting after drinking. He gets headaches whenever he drinks and talks over-the-counter aspirin to relieve the headache. He reports taking Estazolam every day to help sleep. My drinking is getting worse daily, and I cannot do anything meaningful for myself. I no longer go out with friends during the weekend for fear of drinking too much.(Comprehensive Soap Note Example Essay on Mental Health)

Past Medical Hx:

• Current Medications: Aspirin 325 mg PO q4hr PRN for headache. Estazolam 1 mg PO HS for insomnia.
• Medication trials:
• Psychiatric diagnosis:
• Allergies: No known medication, environmental or food allergies

Family Hx: Married with a daughter aged 11. 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.(Comprehensive Soap Note Example Essay on Mental Health)

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 Soap Note Example Essay on Mental Health)

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. 

CARDIOVASCULAR: No chest discomfort or palpitations.

RESPIRATORY: No wheeze, 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: RY is not well-dressed for the occasion and time. He is cooperative. RY appears to be in distress. Abnormal psychomotor activity is noted during the psychiatric assessment. RY 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 low risk of suicide ideation, self-harm, or harm to others.(Comprehensive Soap Note Example Essay on Mental Health)

Diagnostic Impression:

1. Alcohol use disorder: The client’s symptoms suggest moderate alcohol use disorder (AUD), 90 (FI 0.20). The client’s essential features of AUD include problematic alcohol use patterns, often in large amounts, carvings, failure to fulfil routine obligations, and constant use (American Psychiatric Association, 2019).(Comprehensive Soap Note Example Essay on Mental Health)
2. Major Depressive Disorder: The client’s symptoms also suggest Major depressive disorder (MDD), 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 Soap Note Example Essay on Mental Health)
3. Cannabis Use Disorder: The client’s symptoms suggest cannabis use disorder (CUD), 23 (F32.2). The essential features of CUD include taking cannabis in large amounts, 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 Soap Note Example Essay on Mental Health)

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.

Treatment Plan: 

#99221

Admit the patient as per the mental examination and HPI for seven days. The client is not stable 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 Soap Note Example Essay on Mental Health)

#98960

Educate 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 Soap Note Example Essay on Mental Health)

#99607

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.(Comprehensive Soap Note Example Essay on Mental Health)

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 demonstrates a desire to regain normalcy, and CBT will be crucial in achieving a sober state.(Comprehensive Soap Note Example Essay on Mental Health)

Discharge: After seven days.

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7^th ed.). American Psychiatric Publishing, Inc.   

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

FAQs

What is the alcohol use disorder?

Alcohol misuse condition (AMC) is a persistent and potentially serious issue marked by an individual’s struggle to manage their alcohol consumption, disregarding its adverse effects on their physical well-being, social interactions, and daily capabilities. Those affected by AMC frequently encounter desires for alcohol, heightened tolerance, withdrawal symptoms in periods of abstinence, and challenges in moderating or halting their drinking habits. The extent of AMC can vary and demands accurate identification and intervention, potentially encompassing counseling, pharmaceuticals, and adjustments in lifestyle.

What are 5 symptoms of alcohol use disorder?

Alcohol misuse ailment presents with indicators like loss of restraint over drinking, heightened tolerance, withdrawal signs in abstinence, persistent use despite harm, and intense fixation on obtaining alcohol. These manifestations can result in notable debilitation in individual, interpersonal, and professional capacities. The extent of disorder varies and seeking expert assistance is vital for accurate evaluation and successful intervention.

What are the 4 types of drinker?

The four distinct categories of individuals with varying relationships to alcohol consumption are:

1. Those who engage in Social Drinking: These people consume alcoholic beverages primarily in communal environments, exhibiting self-regulation over their intake.
2. Individuals practicing Binge Drinking: This group consumes substantial amounts of alcohol within a compressed timeframe, often with the aim of achieving intoxication, which can lead to compromised well-being and impaired decision-making.
3. Those facing Drinking-Related Concerns: This category involves individuals who might not necessarily indulge excessively at once but display indications of challenges associated with alcohol, including struggles to manage consumption and encountering adverse repercussions.
4. People with Alcohol Dependency: This category encompasses those who have developed both a physical and psychological reliance on alcohol. They might encounter difficulties in governing their drinking habits, encounter withdrawal manifestations during periods of abstinence, and witness significant disruptions in their daily routines due to their alcohol usage.

What is alcohol use disorder DSM?

Alcohol Use Disorder (AUD) is a term found in a particular edition of a well-known diagnostic manual. It denotes an ongoing issue with alcohol consumption that causes noteworthy impairment or distress. AUD involves various symptoms like intense alcohol cravings, inability to limit consumption, withdrawal signs without alcohol, heightened tolerance, and prioritizing alcohol over important obligations. The intensity of AUD varies, encompassing a spectrum of severity levels.