Discuss the most appropriate evidence-based pharmacological and non-pharmacological plan of care.
Assignment 2: Focused SOAP Note and Patient Case Presentation
C E
Walden University
PRAC 6675
Objectives:
- Conduct a detailed comprehensive psychiatric assessment.
- Select the most appropriate primary diagnosis.
- Discuss the most appropriate evidence-based pharmacological and non-pharmacological plan of care.
- Relate social determinants of health for referral to meet the need.
Subjective
CC (chief complaint): “I can’t seem to control my tears! I don’t want to live anymore!”
HPI: ZM is a 60-year-old female who came to the clinic for an initial mental assessment. She reports crying spells all the time all day for the past 5 weeks since she her husband of 40 years divorced her. She reports feelings of sadness, emptiness and worthlessness, and claims she does not want to live anymore. She says she does not enjoy activities like baking, walking their dog or gardening that she found pleasurable before. She reports she enjoys staying in at home alone all day. She reports loss of appetite with a loss of 2.7 kg over the 5-week period. She reports fatigue and sleep problems with only 3-5 hours of sleep per day. She says her concentration is poor, she is more forgetful and is having trouble making decisions that is affecting her performance at work and in performing activities of daily living. However, she denies any thoughts of suicide and claims that would be sinful.
Past Psychiatric History
- General Statement: ZM is experiencing repeated crying spells all day, and feelings of sadness, emptiness and worthlessness with claims of not wanting to live anymore that started after her divorce.
- Caregivers (if applicable): She denies history of a caregiver.
- Hospitalizations: She denies history of hospitalization.
- Medication trials: Denies history of medication trials.
- Psychotherapy or Previous Psychiatric Diagnosis: Denies history of psychotherapy.
- Substance Current Use and History: She declines alcohol, smoking or any history of substance use.
- Family Psychiatric/Substance Use History: She reports both her parents had alcohol and substance-use problems. She denies any knowledge of any psychiatric disorders in her family.
Psychosocial History: ZM is an only child to alcoholic parents. She reports growing up in foster care until she was 11 when she was adopted by her current parents. She reports history of violence and emotional abuse as a child from her biological parents. She got married at 20 years, and her husband recently divorced her. She has two daughters who are married and living in different states with their families, but they visit frequently. She has a Bachelor degree in business administration, and is employed in a manufacturing company.
Medical History:
- Current Medications: She reports taking Tylenol sometimes for headache.
- Allergies: Denies any known food or drug allergy.
- Reproductive Hx: She has two daughters. Not sexually active for the past 6 months. She is post-menopausal.
ROS:
- GENERAL: ZM reports feeling sad, empty and worthless.
- HEENT: No blurred vision, yellowing of the sclerae or double vision. Ears, Nose, Throat: Hearing grossly intact; no sneeze, nasal congestion, nasal drainage; no sore throat.
- SKIN: No rash, pruritus or rash.
- CARDIOVASCULAR: No palpitations; no pain, pressure, or discomfort in the chest.
- RESPIRATORY: Difficulty in breathing, shortness of breath, cough or sputum not noted.
- GASTROINTESTINAL: Declined nausea, vomiting, or diarrhea. Abdominal pain or bloody stool not noted.
- GENITOURINARY: Burning sensation during urination, hesitancy, urgency or odor not noted.
- NEUROLOGICAL: Headache, syncope, dizziness, ataxia, paralysis, tingling sensation or extremities numbness not noted. Declines loss of bladder or bowel control.
- MUSCULOSKELETAL: Muscle, joint or back pain, or stiffness declined.
- HEMATOLOGIC: Easy bruising, bleeding, or anemia not noted.
- LYMPHATICS: Enlargement of the nodes. History of splenectomy not noted.
- ENDOCRINOLOGIC: Declines reports of cold, or heat intolerance. Declines polyuria or polydipsia.
Physical exam:
- General: ZM looks sad and depressed, poorly groomed in bad hygiene.
- HEENT: Normocephalic head. Pupils are equal and reactive to light. The auditory canals are clear, the pinnae are of normal shape, the tympanic membrane is grey bilaterally and no drainage. No enlargement of lymph nodes on the neck. Trachea is midline.
- Skin: Warm and dry. No bruises or lesions.
- Respiratory: No wheezing, crackles or rhonchi. Breath sounds audible and equal bilaterally.
- Cardiovascular: S1 and S2 sounds audible. No heart murmurs. Regular heart rate and rhythm.
- GI: No splenomegaly or hepatomegaly. Abdomen is soft, non-tender and non-distended. Abdominal sounds are normoactive on all the four quadrants.
- Musculoskeletal: No edema, cyanosis or deformities. Movement symmetrical on all extremities without difficulty. Steady gait.
- Vitals: Temp-36.4, PR-76bpm, RR- 12bpm, SpO2-100%.
Diagnostic results: She scored 17 on the PHQ-9 questionnaire (Costantini et al., 2021).
Assessment
Mental Status Examination: ZM is a 60-year-old female who is poorly groomed in poor hygiene. She avoids direct eye contact and breaks down in to tears severally during the interview. She says her mood is sad, and affect is mood congruent. Her speech has a slow, soft monotone. Only speaks when spoken to with single words. Her thought content shows guilt. Concentration, memory and processing speed are fair. Insight and judgment are intact. Denies hallucinations or delusions. No suicidality or homicidally.
Differential Diagnoses:
- Major depressive disorder (MDD): MDD is a mental illness that affects an individual’s mood causing feelings of persistent sadness and inability to have pleasure for weeks or months (Bains & Abdijadid, 2022). ZM is reporting feeling sad, worthless and empty for the past 5 weeks (Bains & Abdijadid, 2022).
- Adjustment disorder with depressed mood: adjustment disorder is a mental disorder that occurs as a reaction to life stressors causing depressive psychological symptoms (Maercker & Lorenz, 2018). ZM got divorced from her husband of 40 years 5 weeks ago and is experiencing a depressed mood, worthlessness and social withdrawal.
- Post-traumatic stress disorder: PTSD is a mental disorder that occurs in response to experiences of traumatic events (Andreasen, 2022). Although ZM has a history of childhood abuse and violence, presents with symptoms of negative mood and cognition alterations like guilt, decreased interest in activities and social isolation, presents with symptoms of arousal and reactivity like trouble sleeping and concentrating, she is not experiencing any intrusion or avoidance symptoms related to the trauma right now (American Psychiatric Association, 2013; Andreasen, 2022). Therefore, she does not meet the criteria for PTSD.
ZM’s primary diagnosis is MDD based on her clinical presentation, history and DSM-5 manual. ZM reports feelings of sadness, emptiness and worthlessness, and is tearful nearly all day most of the days (American Psychiatric Association, 2013). She reports loss of interest in baking, walking their dog or gardening that she found pleasurable before, and prefers staying in the house alone (American Psychiatric Association, 2013). She has poor appetite and has lost 2.7kg over a 5-week period. She is sleeping poorly with only 3-5 hours of sleep per day, feels fatigued, and has difficulty concentrating or making decisions (American Psychiatric Association, 2013). She says her performance at work and at home in performing her activities of daily living is poor (American Psychiatric Association, 2013). ZM symptoms do not meet the full criteria for other mental disorders, and cannot be associated to the effects of substance use or a medical condition (American Psychiatric Association, 2013). She denies any symptoms of mania or hypomania (American Psychiatric Association, 2013). To further support her MDD diagnosis, ZM’s symptoms were triggered by a divorce to her husband of 40 years, and she scored 17 on the PHQ-9 questionnaire indication moderately severe depression (Bains & Abdijadid, 2022; Costantini et al., 2021).
Plan: Based on the diagnosis and the PHQ-9 score, her plan of treatment included a combined therapy with an antidepressant and psychotherapy (Bains & Abdijadid, 2022). The drug of choice for ZM was citalopram 20mg once per day orally (Bains & Abdijadid, 2022; Sadock et al., 2017). Citalopram is a selective serotonin reuptake inhibitor (SSRI) that acts in the central nervous system (CNS) inhibiting presynaptic neuronal reuptake of serotonin causing antidepressant effect (Sadock et al., 2017). In addition, ZM was referred for initiation of cognitive behavioral therapy (CBT) that will help her identify negative thought patterns and behaviors in response to her recent divorce (Bains & Abdijadid, 2022; Lepping et al., 2017). In turn, CBT will help ZM develop constructive and balanced means of coping with the divorce (Lepping et al., 2017). Her follow-up appointment was set-up after 4-6 weeks because SSRIs may take up to 4-6 weeks in order to exhibit therapeutic benefits (Sadock et al., 2017).
One of the social determinants of health that is impacting ZM’s mental health status is lack of adequate social support. ZM is living alone. In order to help ZM increase her social support, I would recommend referring her to a local support group for divorcees, and engage her daughters during her care to improve her coping and form a sense of belonging (Marie, 2022). According to Marie (2022), social support forms protection against depressive symptoms, relieve feelings of social isolation that worsens depressive symptoms, and improve coping to stress that is crucial in recovery in depression.
Reflection notes: I think the assessment was comprehensive, and the diagnosis and plan of care were appropriate for ZM. There is nothing I would do differently. The patient is due for follow-up next week.
Questions:
- Do you agree with the primary diagnosis? If not, what do you think is the most appropriate primary diagnosis?
- Which one other non-pharmacological intervention can you recommend for ZM?
- Is there any additional information you think I should have acquired?
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Pub.
Andreasen, N. C. (2022). What is post-traumatic stress disorder?. Dialogues in clinical neuroscience.
Bains, N., & Abdijadid, S. (2022). Major depressive disorder. In StatPearls [Internet]. StatPearls Publishing.
Costantini, L., Pasquarella, C., Odone, A., Colucci, M. E., Costanza, A., Serafini, G., … & Amerio, A. (2021). Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review. Journal of affective disorders, 279, 473-483.
Lepping, P., Whittington, R., Sambhi, R. S., Lane, S., Poole, R., Leucht, S., … & Waheed, W. (2017). Clinical relevance of findings in trials of CBT for depression. European Psychiatry, 45, 207-211.
Maercker, A., & Lorenz, L. (2018). Adjustment disorder diagnosis: Improving clinical utility. The World Journal of Biological Psychiatry, 19(sup1), S3-S13.
Marie, S., (2022). How Social Support Can Help with Depression. PsychCentral. https://psychcentral.com/lib/social-support-is-critical-for-depression-recovery
Sadock, B., Sadock, V. A., & Sussman, N. (2017). Kaplan & Sadock’s pocket handbook of psychiatric drug treatment. Lippincott Williams & Wilkins.