NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week 7 Discussion GO
PRAC 6675 Across the Lifespan
January 11, 2023
CC (chief complaint): the patient JP reports trouble dealing with anxiety, depression, anhedonia and worrying about school as well as lack of energy.
HPI: The patient JP is a 17-year-old caucasian male that presented to the clinic for a follow-up appointment for the management of his anxiety, depression, and lack of energy. He arrived at the office today with his mother. JP’s first sought treatment at the age of 15 related to his anxiety and depression. At this time, he started falling behind in school and had difficulty keeping up. At the age of 15, he was started on Zoloft, but after about six months did not see much improvement in the symptoms and stopped the medications. The patient has not seen another prescriber since the age of 15. The patient first presented to our clinic about three months ago and since then has been initiated on Effexor and has since been titrated to 112.5 milligrams PO qday. The patient reported an improvement in his symptoms when initiated on 37.5 milligrams qday but only started seeing efficacy when the dosage was titrated to 112.5 milligrams qday. The patient rates his mood to be a 6 out of 10 compared to previous scores of three on the last office visit.
Substance Current Use: JP denies any nicotine use. He does report that at the age of 16, he experimented with drinking alcohol socially with peers on the weekends. He stated that in one sitting, he would have ten beers. The patient states that he has not had any alcohol in approximately six months now. The patient denies any additional recreational drug use. the patient denies any caffeine use.
· Current Medications: Effexor 112.5 mg PO qday
· Allergies: no known drug allergies, no known food or environmental allergies.
· Reproductive Hx: Denies current or previous sexual activity.
· GENERAL: the patient denies any recent weight loss or weight gain. The patient has no complaints of fevers or chills. The patient denies any changes in his energy levels. The patient reports that he's able to sleep approximately 6 to 8 hours nightly without interruption.
· HEENT: The patient's head is symmetrical with no obvious deformities. The patient has no discharge of the eyes, ears, or nose. Throughout the interview, is not noted that the patient had any productive cough or trouble breathing. The patient denies any history of head injuries. The patient also denies any visual disturbances, including double vision or blurry vision.
· SKIN: the patient's skin is normal for ethnicity with no rash observed.
· CARDIOVASCULAR: The patient denies any chest pain or chest discomfort. There is no note of any edema in any extremities. The patient denies any history of heart palpitations.
· RESPIRATORY: The patient can talk in complete sentences without shortness of breath. Throughout the interview, there was no evidence of a cough or the production of sputum.
· GASTROINTESTINAL: The patient denies any nausea, vomiting, or diarrhea. The patient's abdomen is flat and nontender. The patient denies any bloody or tarry stools.
· GENITOURINARY: The patient denies any dysuria or odor coming from his urine. The patient also denies any issues with hesitancy or urgency while urinating.
· NEUROLOGICAL: The patient is alert and oriented times 4 denying any headaches. The patient has equal movement and sensation to all extremities. The patient is also able to ambulate in a steady gait. The patient denies any loss of control of bowel or bladder function.
· MUSCULOSKELETAL: The patient is able to ambulate with a steady gait with no report of backward joint pain.
· HEMATOLOGIC: the patient has no history of abnormal bruising or bleeding. The patient's last CBC was found to be within normal limits. The patient denies any history of anemia.
· LYMPHATICS: The patient had no enlarged lymph nodes, and the patient reports that they have not had any previous surgeries before.
· ENDOCRINOLOGIC: The patient denies polyurea, polydipsia, and polyphagia. The patient also denies any intolerances to heat or cold.
Diagnostic results: vitamin B, vitamin D, CBC, CMP
blood pressure126/70, pulse 70, respiratory rate16 brass a minute, temp 98.4 F
Mental Status Examination:
JP is a 17-year-old caucasian main that appears to be of the stated age. During the interview the patient is calm and cooperative during the exam. The patient is casually dressed and appropriate for the weather today. There was no note of any extra parietal movements from the patient. the patient's speech is of proper volume and rate. The patient’s thought process is linear, logical, and goal-directed. The patient’s mood is good, and the affect is congruent and full range. The patient denies any suicidal or homicidal ideations. The patient also denies any auditory or visual hallucinations. The patient is alert and oriented times four. The patient can recall both remote and recent memories. The patient has good insight into his disease process as well as the treatment plan.
Major depressive disorder-the most likely diagnosis for this patient is a major depressive disorder. The patient is exerting a low or depressed mood, as well as decreased interest in enjoyable activities, a lack of energy as well as changes in his appetite, and these are all symptoms that coincide with major depressive disorder (Akkasheh et al., 2022). Since starting on the new medication, Effexor, the patient's mood has significantly improved as well as his energy. Psychotherapy, in combination with pharmacological approaches has been shown to be the most effective for managing this disorder(Guidi & Fava, 2021).
Generalized anxiety disorder-our patient was also having significant difficulty managing his school work and was reported that it was from his anxiety and feeling overwhelmed. Generalized anxiety disorder usually manifests with excessive unrealistic worrying about common everyday things (Demertzis & Craske, 2022). These symptoms can be debilitating, and in this patient, the situation calls them to fall behind significantly in school as well as in their personal life. It is likely that this patient is suffering from both major depressive disorder and generalized anxiety disorder, and some studies have found that as much as 41.6% of patients suffering from the major depressive disorder also suffer from generalized anxiety disorder period (Kalin, 2020).
Borderline personality disorder-after discussing with my preceptor, I also found that the patient may potentially have a borderline personality disorder. The patient has many traits that coincide with a cluster B borderline personality disorder. Patients that are suffering from this disorder suffer from pervasive patterns of effective instability as well as difficulty with interpersonal relationships (Kulacaoglu & Kose, 2018). There were talks of continuing to assess for this and get confirmation with neuropsychological testing.
I was fortunate that I was able to follow this patient's treatment plan from the beginning And was present when his follow-up appointments. It was interesting how the patient had previously failed a trial of an SSRI for managing the major depressive disorder and generalized anxiety disorder. Typically SSRI's are the first line of treatment for any patriot depressive disorder or generalized anxiety disorder.
After the patient failed to achieve efficacy with the trial of Zoloft, I found it to be interesting that the provider went straight to Effexor. Considering the patient's age and single trial of 1 SSRI, I may have considered using another SSRI before giving up on that drug class.
Knowing the patient’s ability to utilize vitamin B properly could also be a good indicator of why the patient failed to achieve efficacy with Zoloft. Patients that have the inability to utilize vitamin B properly or have low levels of vitamin B have been shown to not respond as well to SSRIs. Sometimes as simple as adding a vitamin B supplement may help to improve the patient's ability to properly metabolize SSRI's.
The patient was referred to psychotherapy, and it would have been good to collaborate more with the therapist on what they've been working on. Having a better understanding of what the therapist has been working on can help to facilitate better proper medication management and develop a more rounded treatment plan.
Getting additional information from the patient’s teachers at school can be helpful in properly diagnosing patients. Understanding how others perceive the individual outside of the clinic can also be helpful in properly assessing, diagnosing, treat patients. Sometimes it is possible that a patient act entirely differently in different settings. Being that this is a school-age kid, this is another resource that we could have tapped into.
Case Formulation and Treatment Plan:
Providing the patient with the emergency crisis hotline if he feels suicidal.
Educate the patient about the available resources in the neighborhood, including the local crisis center end emergency rooms if needed for emergency events.
Educate the patient to use 911 if he is having a medical emergency, including suicidal ideation.
Allow time for interviewing both the parents and the patient during each visit independently.
Continue to titrate the patient’s medications as needed to reach efficacy related to the patient’s anxiety and depression while assessing for adverse reactions.
Consider the usage of neuropsychological testing to rule out other disorders, such as personality disorders.
Utilize both the patient and the family 4 obtain a more detailed history of the patient and family.
Encourage the development of coping skills, including utilizing resources such as friends and family to talk to when having difficult times.
Continuing psychotherapy for management of major depressive disorder and anxiety.
Continue to collaborate with the patient's primary care provider.
Have labs drawn as listed above to rule out another physiological rationale for the patient's symptoms.
Questions for Classmates
1. What additional nonpharmacological recommendations would you have for a patient suffering from major depressive disorder and or generalized anxiety disorder?
2. Do you agree with my preceptor’s recommendation to change his medication from Zoloft to Effexor? What other medications would you have considered prior to starting Effexor after the failed trial of Zoloft?
3. For patients suffering from major depressive disorder, how would your treatment plan differentiate from an adolescent to an adult?
4. What resources are available in your area to assist patients that are suffering from suicidal ideation or an exacerbation of their depressive symptoms?
Akkasheh, G., Kashani-Poor, Z., Tajabadi-Ebrahimi, M., Jafari, P., Akbari, H., Taghizadeh, M., Memarzadeh, M., Asemi, Z., & Esmaillzadeh, A. (2022). Major depressive disorder. Nutrition (Burbank, Los Angeles County, Calif.), 32(3), 315–320.
Demertzis, K. H., & Craske, M. G. (2022). Generalized anxiety disorder. Practitioner's Guide to Evidence-Based Psychotherapy, 301–312. https://doi.org/10.1007/0-387-28370-6_30
Guidi, J., & Fava, G. A. (2021). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder. JAMA Psychiatry, 78(3), 261.
Kalin, N. H. (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365–367.
Kulacaoglu, F., & Kose, S. (2018). Borderline personality disorder (bpd): In the midst of vulnerability, chaos, and awe. Brain Sciences, 8(11), 201. https://doi.org/10.3390/brainsci8110201
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