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Please use the information below to write an outpatient Expanded SOAP Note. Also write a self-reflection that discuss a clinical encounter that was particularly interesting and what you learned from it? Also, attached is an example of Expanded SOAP Note
Chief Complaint:
“A little bit depressed, all my life”.
HPI:
L.D is a 21 year old female with a past medical history of UTI, rectal bleeding, severe recurrent major depression, developmental dysplasia of the hip, and amblyopia, who presents to the ED for evaluation of suicide attempt. Patient presents today after what appeared to be a suicide attempt. She was found on the bridge and had her feet over the edge and was attempting to jump and was had to be removed by bystanders. Patient is 4 months postpartum she has been having marked increase in depression for the last 2 to 3 months and is actively suicidal patient has a previous history of severe depression postpartum and had an attempt years ago including an overdose of Wellbutrin which landed her in the ICU. Patient once again is high risk and will be evaluated by the DEC assessor as well.
The patient has a history of depression, anxiety, binge eating disorder, possibly autism spectrum disorder. The patient is a good historian. She is minimizing the reason she is in the hospital. States she is “a little depressed” and has been “all my life”. She reports being stressed out by having a newborn baby and living with her father. The father of the baby lives in a sober home and is not able to help out. The patient minimizes the suicide attempt stating that she did not mean to do it. She wants to be discharging because nobody is able to watch for child while she is in the hospital. The baby is currently with her mother. Reminded the patient that if there was not a bystander to pull her out of the bridge, she would have been that now and her family needing to figure out who to take care of her permanently.
While in the emergency room, the patient reported severe depression for 3 months. Today, she is reporting moderate depression. Mood have been low. Sleeps 6 hours a night. Does not take naps during the day. Energy is low. Denies problems with memory and concentration. Appetite is good. Denies suicidal ideation and self-harm. Denies homicidal ideation. Denies feeling hopeless, helpless, and worthless. Anxiety is bed most of the time. She is having panic attacks manifesting with increased heart rate and racing thoughts. Smoking cigarettes help. The patient denies history of manic episodes. She does have an uncle with bipolar disorder. Denies auditory visual hallucinations. Reports some low-grade paranoia of feeling that people are talking behind her back. The patient reports sexual assault. For a while she had nightmares but not now. Has been having increased flashbacks recently. The patient reports history of bulimia followed by binge eating. She was at the Emily program in 2021 and was discharged due to making homicidal statements. The patient denies official diagnosis of borderline personality disorder however, it came up with one of her therapist who felt that she may have it. Reports 1 suicide attempt by overdosing on Wellbutrin. Patient ended up in the ICU. She reports history of SIB by cutting. Denies seizures, head injuries, and loss of consciousness.
The patient has not been on medications for at least a year. She does not have a mental health provider or therapist. Per chart review, the patient was seen by Dr. Bagdade who concluded that the patient has visual depressive disorder, generalized anxiety disorder, feeding/eating disorder and to rule out autism spectrum disorder.
Spoke with patient’s mother Nicole Staeheli. States that the patient has always minimized her mental health symptoms. She was hospitalized at Duluth after a suicide attempt by overdosing on Wellbutrin. She was court committed at that point and sent to a residential MICD program where she was sexually assaulted. She was only girl in the program. After the IRTS, the patient went to live in a boarding Lodge. She became pregnant. For a while, she and her brother friend were living on the street. When she felt pregnant, she came back to this Twin Cities. Recently, the patient has been using diet pills. She has been upset about the weight gain. She has been having a lot of irrational thoughts since then. She has been accusing her neighbor of sexually assaulting her as a child. She has accused her mother of calling her name and threatening to cut her hair. She has been irritable and angry. She has been convinced that that these things have happened even though have her family have tried to convince her that none of it is true. The family feels that the patient needs EMDR or trauma based therapy of any kind. The patient has a history of noncompliance with her medications. She usually takes it for a week and then either overdose or stopped taking them. She has been refusing to see a psychiatrist. The family is wondering if a mother/child program would be beneficial for her. She seems to be quite isolated. Patient’s brother has significant autism.
Past Psychiatric History:
The patient has a history of depression, anxiety, binge eating, possibly autism. This is her third hospitalization for mental illness. Prior medication trials include Zoloft and Prozac which have not been helpful, Effexor which she did not take long enough, Wellbutrin, hydroxyzine. Reports suicide attempt by overdosing on Wellbutrin and SIB by cutting. Currently does not have a psychiatrist or therapist.
Substance Use and History:
The patient drinks alcohol 2-3 times a month usually 1 drink of bourbon. She does not get intoxicated. She smokes cigarettes about 5 a day. She does not use any other substances and have never experimented with anything else.
Past Medical History:
PAST MEDICAL HISTORY:
Past Medical History
Past Medical History:
Diagnosis Date
• Amblyopia, unspecified 06/01/2005
R eye
• Depressive disorder
• NEONATAL JAUNDICE
• Other congenital deformity of hip (joint) 04/01/2005
Right
PAST SURGICAL HISTORY:
Past Surgical History
Past Surgical History:
Procedure Laterality Date
• SURGICAL HISTORY OF – 7/13/05
R hip surgery
• SURGICAL HISTORY OF – 4/2006
R fem palte removal with Arthrogram
Family History:
FAMILY HISTORY:
Family History
Family History
Problem Relation Age of Onset
• Diabetes Maternal Grandfather
• Diabetes Paternal Grandfather
• Hypertension Paternal Grandfather
Positive for an uncle with bipolar disorder. Anxiety and depression runs in the family and so is alcohol.
Social History:
The patient is from Minneapolis. She has 1 sister and 1 brother. She is single. He has a 5-month-old daughter. Currently lives with her father and her baby. Her boyfriend who is the father of the child lives in a sober home and is not able to help her. She does not work or go to school. Completed some college. Denies military and legal history.
Physical ROS:
The patient denies acute physical issues.. The remainder of 10-point review of systems was negative except as noted in HPI.
PTA Medications:
Prescriiptions Prior to Admission
Medications Prior to Admission
Medication Sig Dispense Refill Last Dose/Taking
• hydrOXYzine (ATARAX) 25 MG tablet Take 1-2 tablets (25-50 mg) by mouth every 6 hours as needed for anxiety or other (sleep) 30 tablet 0 11/23/2024 Bedtime
Allergies:
Allergies
No Known Allergies
Labs:
Recent ResultsExpand by Default
Recent Results (from the past 48 hours)
HCG qualitative urine (UPT)
Collection Time: 11/24/24 3:08 PM
Result Value Ref Range
hCG Urine Qualitative Negative Negative
Urine Drug Screen Panel
Collection Time: 11/24/24 3:08 PM
Result Value Ref Range
Amphetamines Urine Screen Negative Screen Negative
Barbituates Urine Screen Negative Screen Negative
Benzodiazepine Urine Screen Negative Screen Negative
Cannabinoids Urine Screen Negative Screen Negative
Cocaine Urine Screen Negative Screen Negative
Fentanyl Qual Urine Screen Negative Screen Negative
Opiates Urine Screen Negative Screen Negative
PCP Urine Screen Negative Screen Negative
Physical and Psychiatric Examination:
BP 116/81 | Pulse (!) 124 | Temp 98.1 °F (36.7 °C) (Oral) | Resp 16 | Ht 1.727 m (5′ 8″) | Wt 91.2 kg (201 lb) | SpO2 98% | BMI 30.56 kg/m²
Weight is 201 lbs 0 oz Body mass index is 30.56 kg/m².
Physical Exam:
I have reviewed the physical exam as documented by the medical team and agree with findings and assessment and have no additional findings to add at this time.
Mental Status Exam:
Appearance: awake, alert and well groomed
Attitude: cooperative and evasive
Eye Contact: good
Mood: anxious and depressed
Affect: mood congruent
Speech: clear, coherent
Language: fluent and intact in English
Psychomotor, Gait, Musculoskeletal: no evidence of tardive dyskinesia, dystonia, or tics
Thought Process: logical and goal oriented
Associations: no loose associations
Thought Content: no evidence of suicidal ideation or homicidal ideation, no auditory hallucinations present, and no visual hallucinations present
Insight: limited
Judgement: limited
Oriented to: time, person, and place
Attention Span and Concentration: intact
Recent and Remote Memory: intact
Fund of Knowledge: appropriate
Diagnoses:
Major depressive disorder, recurrent, severe, without psychosis
Generalized anxiety disorder
Suicide attempt
Tobacco use disorder
Mild alcohol use
Assessment & Plan:
Medications:
–Start Cymbalta, 40 mg every morning for depression and anxiety
–Start trazodone, 50 mg at bedtime for sleep
–Start nicotine patch, 40 mg every morning
–Additional medications will include hydroxyzine, Zyprexa, and trazodone
Lab work:
Lab work was reviewed. U tox was negative. Blood work was not done.
–CBC, CMP, TSH with T4, vitamin D, B12, and folate were ordered.
Consults:
Internal medicine to follow up for medical problems.
Care was coordinated with the treatment team.
The patient was consulted on nature of illness and treatment options.
Disposition Plan
Reason for ongoing admission: poses an imminent risk to self
Discharge location: home with family
Discharge Medications: not ordered
Follow-up Appointments: not scheduled
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