Posted: September 7th, 2024

SOAP Note on Mental Health

Signature assignment
SOAP Note on Mental Health

Name xxx
United State University
Couse xxx
Professors xxxx
Date xxx
Video link
SOAP Note on Mental Health
Patient Initials: P.S. Age: 21; is a Hispanic male who visits the clinic unaccompanied and seems to be a reliable historian.
Subjective
CC: “I am feeling depressed.”
HPI: The patient is a 21-year-old male Hispanic college student. He has complaints of feeling depressed. He says that ever since he broke up with his girlfriend two months ago, he has had a broadly depressed attitude and has not been enjoying life to the fullest possible extent. He also reports having trouble sleeping on occasion. He is frequently anxious and overthinks the possibility of ever finding true love. He is now failing exams and scoring poor grades. He denies night sweats, fever, chills, fatigue, nausea, or vomiting.
Past Medical History
Chronic illness: None
Medication: None
Allergies: No known allergies
Surgeries: None
Social History
• He is a college student
• Broke up with his girlfriend 2 months ago
• Drinks alcohol 1 bottle of beer per day since he broke up with his girlfriend.
• Smokes cannabis daily since he broke up with his girlfriend.
• Denies smoking tobacco
Family History
• His father died in a tragic road accident.
• Mother has no known chronic illness
• PGF alive has hypertension
• PGM diseased, no known chronic illness
• MGF diseased, no known chronic illness
• MGM diseased, no known chronic illness
Review of Systems
Constitutional: Denies chills, fever, chest pain, or weight loss.
Head: Denies unconsciousness or head trauma.
Eyes: No eye irritation, color blindness, dryness, or copious tears reported. Denies using
corrective lenses.
Ears: Denies experiencing ear pain, ear ringing, discharges, or hearing loss.
Nose: No nosebleed, loss of smell, nasal congestion, or pain reported.
Mouth: Does not experience bleeding gums or mouth wounds.
Throat: No sore throat and hoarseness reported.
Skin: Denies skin rashes, bruises, color changes, or lesions.
Respiratory: He denies having any symptoms of coughing, wheezing, difficulty breathing, or
chest pain.
Cardiovascular: Denies heart palpitations and denies having chest pain or tachycardia.
Genitourinary: Denies having pain, abnormal penile discharge, or urination frequency changes.
Musculoskeletal: Denies having joint pain, muscle pain, or swelling.
Heme/Lymph/Endo: He denies experiencing excess sweating. He denies a history of blood
transfusion.
Neurologic: No dizziness, headaches or tremors, or syncope have been reported.
Psychological: Denies suicidal thoughts or memory loss. Reports depression and anxiety.
Objective
Vital Signs
Blood Pressure: 125/74mmHg Pulse 82. Temperature: 98.5F Respiration 18. SaO2: 99% Height: 5’5” Weight: 148lbs BMI 24
General appearance: The patient is conscious, oriented, and well-groomed. He seems disturbed.
Head: normocephalic, symmetric, atraumatic
Ears: T.M. intact and pearly gray with the cone of light bilat. Pinna clean, no exudate noted.
Eyes: Normal PERRLA findings. Anicteric sclera.
Nose: No maxillary sinuses, lesions, or bleeding. The mucous membrane is moist.
Throat: No lesions, exudate, or inflammation.
Skin: Soft, warm, supple, and dry. There are no rashes, bruising, or changes in skin color.
Cardiovascular: Normal S1 and S2 sounds. Regular heartbeat.
Gastrointestinal: No palpable masses. Soft, non-distended, and non-tender abdomen.
Respiratory: Lung auscultation indicates no abnormalities. No wheezes
Musculoskeletal: No joints or muscles that are inflamed or stiff.
Extremities: No discernible edema.
Neurological: Gait is normal, and balance is stable. Clear communication with a clear tone of voice.
Psychiatric: He is cooperative, alert, and has a pleasant disposition and conduct.
Assessment
1. Depression (F33.1)- Depression is characterized by persistent sadness and lack of motivation. Depression, also known as major depressive disorder, can cause a variety of emotional and physical challenges (SAMHSA, 2021). At times, a person may feel that life has no purpose and find it hard to perform daily tasks (SAMHSA, 2021). This is the most likely differential diagnosis as evidenced by symptoms of feeling sadness from the previous breakup, frustration, smoking cannabis and drinking alcohol.
2. Attention deficit hyperactivity disorder (ADHD) (F90.9)- is one of the most prevalent childhood neurodevelopmental disorders (Cabral et al., 2020). It is most commonly diagnosed in childhood but can last into adulthood if left untreated. Patients with ADHD may struggle to pay attention, control their impulsive behaviors, or engage in an excessive activity (Cabral et al., 2020). The possibility of this diagnosis is due to school inattentiveness and poor grades. However, the differential diagnosis is ruled out because he began scoring low grades after a loss of concentration due to a breakup with his lover.
3. Substance use disorder (F19. 10) – is a mental condition that impacts both the brain and behavior of a person, resulting in that person’s inability to exercise self-control regarding the consumption of substances like alcohol, drugs or medications (Kalin, 2020). Likely differential diagnosis is evidenced by the use of cannabis and alcohol consumption (Kalin, 2020). Ruled out by DSM-5 criteria.
Final Diagnosis: Depression
Plan
Diagnostic Tests
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) – The DSM-5 defines major depression and substance use disorder as five or more episodes of despair within two weeks and disregarding the negative effects of continued substance use (Dubovsky et al., 2021). The DSM-5 can helps classify and determine the severity of depression or substance use disorders.
Complete Blood Count (CBC) – In some cases, medical illnesses such as anemia, autoimmune illness, or vitamin deficiency can mimic the symptoms of depression. In order to rule out other medical disorders that could be confused for depression, a complete blood count can be beneficial (Selph & McDonagh, 2019). In this case, the patient CBC is normal.
Treatment Plan
Depression symptoms may be treated with venlafaxine tablets or capsules (Bandelow et al., 2022). Patients begin with 75mg/day and gradually increase their dosage to 375mg/day (Bandelow et al., 2022). Therefore, it is recommended that the patient take Venlafaxine 75mg/day ER 1 Tablet twice a day by mouth for one month. The dose will be increased at the next appointment.
Patient Education:
1. To abstain from the use of cannabis and drinking alcohol.
2. Exercises can improve treatment outcomes for many depressed patients (SAMHSA, 2021). Encouraged the patient to have regular exercises, yoga, and meditation.
3. Encouraged to get enough sleep
4. Encouraged to eat a healthy diet (SAMHSA, 2021).
Referral: Referred to a physiotherapist
Follow-up: Return in 14 days for reevaluation, or sooner if symptoms worsen.
Evidence-Based Practice
Introduction
I have chosen this soap note about mental health because there has been an evident rise in mental health problems on college campuses over the past few years. This trend is considered to be a major mental health crisis that calls for quick intervention. Depression, anxiety, and other forms of behavioral and cognitive disorders are all part of one’s mental health. Students in their twenties are at especially high risk for developing many of the symptoms associated with mental illness. This paper covers three evidence-based articles and practices for diagnosing, preventing and treating common mental health issues, which include insight meditation, stress management, acceptance and therapeutic intervention, behavioral therapy, and counseling.
Evidence-based articles:
• Dubovsky, S. L., Ghosh, B. M., Serotte, J. C., & Cranwell, V. (2021). Psychotic depression: Diagnosis, differential diagnosis, and treatment. Psychotherapy and Psychosomatics, 90(3), 160–177. https://doi.org/10.1159/000511348
• SAMHSA. (2021). Prevention and treatment of anxiety, depression, and suicidal thoughts and behaviors among college students. https://archive.hshsl.umaryland.edu/handle/10713/16957
• Selph, S. S., & McDonagh, M. S. (2019). Depression in children and adolescents: Evaluation and treatment. American Family Physician, 100(10), 609–617. https://www.aafp.org/pubs/afp/issues/2019/1115/p609.html
Diagnosis
To make a diagnosis of major depressive disorder, the DSM-5 criteria must be met (Selph & McDonagh, 2019). These criteria cannot be explained by drug abuse, medication use, or any other medical or mental condition (Selph & McDonagh, 2019). When a teen tests positive on a formal screening instrument or appears with symptoms suggesting a possible depression, the healthcare professional is recommended to determine whether the complaints are due to a severe depressive state or another ailment that could manifest with comparable symptoms. In some cases, medical illnesses such as anemia, autoimmune illness, or vitamin deficiency can mimic the symptoms of depression (Selph & McDonagh, 2019). In order to rule out other medical disorders that could be confused for depression, a complete blood count or thorough metabolic profile panel can be beneficial.
Risk factors
In the 10-24 age group, suicide is the second greatest cause of mortality after unintentional injury (Selph & McDonagh, 2019). There is a link between depression and suicide, but young people who are at risk may go unnoticed until they undergo suicide screening (Selph & McDonagh, 2019). Therefore, these studies have advocated appropriate interventions to prevent suicides.
Management
For mild depression that may not last long, active support like counseling and pharmacotherapy treatment options, helping the patient take care of their own depression is firstly recommended before starting pharmacotherapy (Dubovsky et al., 2021). Depressive symptoms can often be alleviated through physical activity, and numerous studies have found this to be effective in achieving this goal (Dubovsky et al., 2021). Participation in organized exercise has shown potential for relieving depressive symptoms. Exercise and depression have been linked since the early 1900s by scholars (Selph & McDonagh, 2019). Case studies conducted in the past concluded that exercise of moderate intensity should be useful for depression and should result in a happy mood for some individuals. As a result of these studies, that is why we recommended the patient practice regular exercises and refer him to a psychotherapist.
Holistic Approach
A holistic approach to mental healthcare aims to treat the whole person, not just the disease symptoms, rather than just the disease itself (Hughes et al., 2021). Mental health professionals that use a holistic approach to patient care will take a step back to get a more comprehensive picture of their patient’s overall health (Hughes et al., 2021). Health care providers need to be aware of a patient’s lifestyle and relationships to better treat them. Before developing a care plan, it is crucial to comprehend the interrelationships between all physiological systems and lifestyle factors (Hughes et al., 2021). As part of a comprehensive approach to mental health, the patient, family, and community are also supported.
Holistic mental health care offers various advantages to patients. For instance, some individuals with mental health concerns may also feel anxious and have insomnia, exhaustion, and other health problems (Hughes et al., 2021). The treatment process can become more challenging when these physical health problems are accompanied by a mental health condition. Addressing these additional health concerns concurrently improves patient outcomes in each of these areas.
Other patient advantages of a holistic mental health approach include dietary and physical exercise enhancements. These modifications can aid in reducing anxiety, sleeplessness, sadness, and mood swings (Hughes et al., 2021). Utilizing a patient’s thinking as a healing tool. This is accomplished by assisting patients in reframing how they see, understand, and respond to specific circumstances and stimuli. This can be as successful as psychotropic medication administration. Educating how to deal with stress. Typically, stress is a cause of a variety of mental health issues (Hughes et al., 2021). In addition to being crucial for a patient’s overall improvement in health, stress management plays a crucial role.
Patients can also get many benefits from taking a holistic approach to psychiatric care, which includes paying attention to how they take care of their spiritual selves. Studies have shown that a strong sense of spirituality fosters self-esteem, enhances motivation, and assists individuals in making meaning of intense interior experiences (Hughes et al., 2021). According to medical studies, spiritual persons engage in fewer self-destructive activities such as drug and alcohol abuse, gambling, and taking unnecessary risks.
Examples How to Collaborate with the Patient’s Family and Other Members and Cultural Factors.
For best care in these complex conditions, both patients and physicians must be involved in which we involved the patient and our clinical team, whereby we refer the patient to a psychotherapist to help the healing (Bombard et al., 2018). Clinicians provide information and recommendations based on their scientific knowledge of therapy and intervention options, as well as their knowledge of prospective outcomes (Bombard et al., 2018). We should have involved the family and cultural considerations because it has the first-hand experience with the benefits and drawbacks of various treatments in light of the patient’s unique set of circumstances and preferences (Bombard et al., 2018). To choose the appropriate care choice, it is necessary to gather data from both sources.
Patient-centered treatment does not entail agreeing to every request. An important part of this process is to interact with the patient and develop an open line of communication about the information that is available as well as the decisions that will be made (Bombard et al., 2018). There are many factors that go into providing patient-centered care, and it can be difficult and time-consuming to include everyone who has a stake in the patient’s well-being in that process.
Jean Watson Caring Process Considering our Patient
Jean Watson suggests that compassion regenerates vital energy and bolsters our capacities (Wei & Watson, 2019). The benefits are immense and promote both personal and professional self-actualization. We must also remember that Watson highlights the importance of taking care of oneself in order to take care of others; self-healing is an essential step for restoring our vitality and recharging our mental bank (Wei & Watson, 2019). Taking care of others is a win-win situation for everyone involved: patients, families, and health caregivers. As a result, we believed that showing compassion to the patient and encouraging him to care for himself as a form of self-healing could help him generate vital energy.
Representative of a Holistic Approach to Our Patient
As a representative of a holistic approach, we used treatment strategies focusing on energy or movement-based, biological, or anchored in functional nutrition. We implemented dietary modifications and nutritional supplements as a change in lifestyle; we encouraged mind-body exercises like yoga and tai chi, physical exercise, discussion, art, and massage treatment. We also involved other clinicians as part of this therapy whereby we referred our patient to a psychotherapist. In addition, we should have included the family in the therapeutic planning process.
In conclusion, both psychotherapy and antidepressants are common forms of treatment for depressed teens. We also used the holistic approach strategies, which took everything into account. Our plan focused on mental, emotional, physical, spiritual, and social health. We thought that one plan could not work without the other. That is why, in addition to pharmacotherapies, we also used exercise management and counseling. Exercise’s antidepressant effects are still up in the ability to reduce symptoms of depression. During exercise implementation, follow-up interaction may also be necessary. Henceforth, motivation and encouragement for exercise activity can be greatly enhanced.
References
Bombard, Y., Baker, G. R., Orlando, E., Fancott, C., Bhatia, P., Casalino, S., Onate, K., Denis, J.-L., & Pomey, M.-P. (2018). Engaging patients to improve quality of care: a systematic review. Implementation Science: I.S., 13(1). https://doi.org/10.1186/s13012-018-0784-z
Dubovsky, S. L., Ghosh, B. M., Serotte, J. C., & Cranwell, V. (2021). Psychotic depression: Diagnosis, differential diagnosis, and treatment. Psychotherapy and Psychosomatics, 90(3), 160–177. https://doi.org/10.1159/000511348
Hughes, S., Rondeau, M., Shannon, S., Sharp, J., Ivins, G., Lee, J., Taylor, I., & Bendixsen, B. (2021). A holistic self-learning approach for young adult depression and anxiety compared to medication-based treatment-as-usual. Community Mental Health Journal, 57(2), 392–402. https://doi.org/10.1007/s10597-020-00666-9
Kalin, N. H. (2020). Substance use disorders and addiction: Mechanisms, trends, and treatment implications. The American Journal of Psychiatry, 177(11), 1015–1018. https://doi.org/10.1176/appi.ajp.2020.20091382
SAMHSA. (2021). Prevention and treatment of anxiety, depression, and suicidal thoughts and behaviors among college students. https://archive.hshsl.umaryland.edu/handle/10713/16957
Selph, S. S., & McDonagh, M. S. (2019). Depression in children and adolescents: Evaluation and treatment. American Family Physician, 100(10), 609–617. https://www.aafp.org/pubs/afp/issues/2019/1115/p609.html
Wei, H., & Watson, J. (2019). Healthcare interprofessional team members’ perspectives on human caring: A directed content analysis study. International Journal of Nursing Sciences, 6(1), 17–23. https://doi.org/10.1016/j.ijnss.2018.12.001Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational Pediatrics, 9(Suppl 1), S104–S113. https://doi.org/10.21037/tp.2019.09.08

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