ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS Focused SOAP Note – assignmenthandlers
ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS Focused SOAP Note
Introduction
In young adults, identification and management of mood symptoms can be challenging for clinicians. Tolliver & Anton (2015) claim the prevalence of comorbid mood disorders among these individuals increases. Thus, a thorough family and medical history assessment are often critical to implementing an optimal treatment plan. Failure to identify mood disorders increases the rates of relapse, recurring mood disorders, and suicidal rates. This paper aims to develop a focused soap note of a young-adult patient with a mood disorder, assess and develop a differential diagnosis list, and implement a treatment plan.
Chief complaint: The patient is visiting the clinic for a mental health assessment.
HPI: Petunia Park is a 24-year-old patient who presents to the clinic for a mental health assessment. She reports having a history of taking medications and stops as she feels she doesn’t need them, and they squash her. Ms. Park also says she has hypothyroidism and is currently under medication.
Past Psychiatric History
General statement: The patient first encounter with mental health was when she was a teenager, and after, she went for five days without sleep. She is unsure of what her mental condition was at that time.
Caregiver: She lives with her boyfriend when she is not at home with her mother. He has been somewhat of a support system for her.
Hospitalization: She reports previous hospitalizations four times before; the last time was during the past spring. She says her hospitalization in 2017 was due to a Benadryl overdose. The Patient denies any detox or residential rehabilitation.
Medication trial: Ms. Park reports she tried Zoloft, which made her feel high, risperidone and Seroquel, which made her gain significant weight, and Klonopin, which slowed her down. She also reports an uncertain medication that “squashed” her creativity ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS Focused SOAP Note.
Previous psychiatric diagnosis: She reports a history of depression, anxiety, and bipolar disorder.
Substance Use History: The Patient reports smoking about a pack a day, admits to taking alcohol at 19, and tried marijuana, which caused paranoia. Denies using cocaine, stimulants, inhalants, sedative medication, and synthetic substances.
Family psychiatric/substance use history: Pt’s mother has a history of bipolar and suicidal attempts. The father went to prison for drugs and claimed his brother is a little ‘schizo’ but has never visited a doctor.
Social History: The client was raised by her mother and older brother. She has one older brother and lives partially with her boyfriend. The client is single with no children. She is currently in vo-tech school for cosmetology and enjoys writing and painting as her hobbies. She works part-time at her aunt’s bookstore. She reports having been taken by police to the hospital once. The client denies any traumatic or violent experiences.
Medical History: The client has hyperthyroidism, and she takes medication. She reports having depression that prevents her from working in the bookshop. During her depression episode, she has no energy or motivation, does not want to get out of bed, and feels unworthy after being up and working for five days.
Current Medication: Medication for hypothyroidism.
Allergies: Denies allergy.
Reproductive Hx: Client reports she is heterosexual, has regular menses, has no pregnancy, is not lactating, and takes a birth control pill for polycystic ovaries. She admits to having multiple sexual partners.
ROS
GENERAL: The Patient is alert and oriented but agitated with some questions. Denies fever, chills, weakness, and fatigue. She reports having a good appetite and sleeping 5-6 hours on average.
HEENT: Denies headache and dizziness. No visual loss, blurred vision, or double vision. No ear pain or loss, no sinus allergies and infection. No neck stiffness, pain, or injury. No past dental examination.
SKIN: No skin rash, itchiness, or wounds.
RESPIRATORY: No chest pains, breath shortness, hemoptysis, congestion, coughs, or edema.
CARDIOVASCULAR: No palpitations, wheezing, murmurs, or chest pains.
GASTROINTESTINAL: No abdominal pains, nausea, diarrhea, or anorexia.
GENITOURINARY: No burning urination, urgency, odor, or discoloration.
NEUROLOGICAL: Patient reports episodes of abnormal sleep patterns, decreased energy, and feeling of worthlessness ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS Focused SOAP Note.
MUSCULOSKELETAL: No muscle cramps, muscle weakness, painful joints, or stiffness.
HEMATOLOGY: No anemia or bleeding.
LYMPHATIC: No nodes enlarged and no splenectomy.
ENDOCRINE: No sweating, heat, or cold intolerance.
Objective
Physical exam: Temp 98.2, Pulse 90, Respiration 18, B/P 138/88.
The Patient is alert and oriented but seems agitated when some questions are asked. She is appropriately groomed and gives information adequately.
Diagnostic Results: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H).
Assessment
Mental Health Examination
The Patient is a 24-year-old female who appears anxious and easily agitated. She is alert and oriented to place and time. She is appropriately groomed and maintains eye contact throughout the interview. Her speech was clear but pressured at times; however, during the interview was able to comprehend what she was verbalizing. She can express thoughts and feelings without hallucination, delusion, or paranoia. Patient reports having depressed mood episodes after five days of working hard. During the episodes, she has no energy or motivation, does not want to get out of bed, and feels unworthy.
Differential Diagnosis
Manic Depression: Calabrese et al. (2017) cite the diagnostic criteria for bipolar disorder as the Patient must experience abnormal and persistent elevated or irritable mood, goal-directed energy lasting for one week and present most of the day, during mood disturbances, the Patient present with increased energy and at least four of the following decreased sleep, inflated self-esteem, more talkative than usual and excessive involvement in pleasurable activities. The Patient reports having depressed mood episodes after five days of working hard. During the episodes, she has no energy or motivation, does not want to get out of bed, and feels unworthy.
Major depressive disorder: The DSM-5 diagnostic criteria for MDD is the Patient must present with either depressed mood or loss of interest for at least two weeks and have at least five other symptoms, including loss of interest, depressed mood, weight loss, insomnia, suicidal thoughts, decreased concentration, fatigue, and retardation (Tolentino & Schmidt, 2018). The Patient reports a depressed mood and loss of interest, which elapses after one week.
Premenstrual dysphoric disorder: According to Reid (2017), the diagnostic criteria is the Patient, during or before their menstrual cycle, must present with at least marked affective lability and irritability and at five of depressed mood, anxiety, decreased interest in activities, difficulty in concentration, change in appetite and insomnia.
The accurate diagnosis for the Patient is manic depression. This is because the Patient presents with depression episodes when she feels she has no energy or motivation, does not want to get out of bed, and feels unworthy, which happens after she has had lots of energy and done a lot of work. She reports the episodes last for a week.
Treatment Plan
The treatment plan is based on several patient factors, including current medication, previous drug reactions, and existing comorbidities will guide the implementation of a treatment plan. In addition, the treatment plan should be re-evaluated and modified as needed. The treatment option for the Patient is initiating Valproate 250mg BD rather than lithium as she has hyperthyroidism which may be worsened by lithium. According to Shah et al. (2017), Valproate has been studied and proven effective in treating acute mania. The medication is associated with less severe side effects but educating the Patient on possible signs of hepatic and hematological dysfunction is significant. It is essential to monitor serum valproate levels and reduced symptoms of mania to determine whether to increase or discontinue the medication (Shah et al., 2017). It is also necessary to recommend the Patient develop a consistent and healthy daily routine that effectively stabilizes moods.
Reflection
The case study was very insightful as I identified that diagnosis of mood disorders involves a thorough evaluation to arrive at the correct diagnosis. Different mood disorders share common signs and symptoms; thus, a diagnostic tool is essential in ruling out possible differential diagnoses. In addition, I learned that treatment is guided by the diagnosis while considering other patient factors. What I would do differently is involve the Patient’s caregiver, as I believe their information would be insightful. Ethical considerations include informed consent and confidentiality. Specific social determinants of health might increase the risk for a mood disorder, including ethnicity, gender, and sexual orientation, low income, and low educational status. ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS Focused SOAP Note Thus clinicians must consider all factors when recommending health promotion strategies.
References
Calabrese, J. R., Gao, K., & Sachs, G. (2017). Diagnosing mania in the age of DSM-5. American Journal of Psychiatry, 174(1), 8–10. https://doi.org/10.1176/appi.ajp.2016.16091084
Reid RL. Premenstrual Dysphoric Disorder (Formerly Premenstrual Syndrome) [Updated 2017 Jan 23]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Table 1, Diagnostic Criteria for Premenstrual Dysphoric Disorder (PMDD) Available from: https://www.ncbi.nlm.nih.gov/books/NBK279045/table/premenstrual-syndrom.table1diag/
Shah, N., Grover, S., & Rao, G. P. (2017). Clinical practice guidelines for management of bipolar disorder. Indian Journal of Psychiatry, 59(5), 51. https://doi.org/10.4103/0019-5545.196974
Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00450
Tolliver, B. K., & Anton, R. F. (2015). Assessment and treatment of mood disorders in the context of substance abuse. Dialogues in Clinical Neuroscience, 17(2), 181–190. https://doi.org/10.31887/dcns.2015.17.2/btolliver
ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS
It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.
