SOAP NOTE GERIATRIC EXAMPLE

Focused SOAP Note and Patient Case Presentation and SOAP NOTE GERIATRIC Example

Subjective:

CC (chief complaint): CD reports, “I am hopeless, helpless, and have not been sleeping well at night.”

HPI: CD is a 60-year-old black female complaining of hopelessness, helplessness, and sleep deprivation. CD has no previous psychiatric encounters. Her caseworker referred CD to the psychiatric clinic for psychiatric evaluation. The client reports sadness and anxiety at all times. She reports being unhappy since her friends treat her like dirt. The client has been sad and depressed for the past 12 months. She has not been treated for depression and has no prior history of mental health illness. She reports thinking about ending her life 8 or 9 months ago. Although the client reports not knowing what caused her depression, she admits to having many issues that have impacted her negatively over the past years. The client reports poor appetite and has to force herself to eat because she has diabetes.

Substance Current Use Denies nicotine, alcohol, cocaine, and marijuana. Denies use of any stimulants or methamphetamines. Does not sniff or inhale any sedative medications. Do not use any hallucinogenic substances.

Family psychiatric/substance use: None reported.

Medication trials: None reported.

Medical History: The client reports type 2 diabetes and hypertension diagnoses.

Past psychiatric history: She denies previous treatment for depression.

Current Medications: Takes Metformin 1000 mg PO BID, Diovan 320 mg PO daily, Hydralazine 25 mg PO TID, Glipizide 5 mg PO daily, Protonix 40 mg PO daily, Lasix 40 mg PO daily to manage diabetes and hypertension.

Reproductive Hx:No reproductive concern. Reports menopause at 50.

Social history: Widowed and lives with a friend. She completed her 10^th-grade high school education. Has a history of sexual and physical abuse. She receives a disability benefit of $783.00.

Allergies:None reported.

ROS:

GENERAL: No fever or chills. Reports weight loss and fatigue.

HEENT: Eyes: Normal vision. Ears, Nose, Throat: Normal hearing, no sneezing, nasal congestion, or sore throat.

SKIN: No skin itching or rashes.

CARDIOVASCULAR: No chest pain, pressure, or discomfort. No palpitations or edema.

RESPIRATORY: Normal breath, No cough or phlegm.

GASTROINTESTINAL: No abdominal pain, vomiting, or diarrhea.

GENITOURINARY: No burning urination, odor, or color.

NEUROLOGICAL: Normal bladder/bowel movement, No dizziness, headache, numbness, paralysis, tingling, or fainting in all extremities.

MUSCULOSKELETAL: No joint stiffness or pain. No muscle or back pain. HEMATOLOGIC: No unusual bleeding or bruising.

LYMPHATICS: Denies splenectomy or enlarged nodes.

ENDOCRINOLOGIC: Reports no sweating, heat, or cold intolerance. No frequent urination or extreme thirstiness.

Objective:Diagnostic results: A T4 concentration test using the equilibrium dialysis technique is necessary to determine whether the client’s

depressive symptoms are associated with underlying hyperthyroidism. Tang et al. (2019) assert that subclinical hyperthyroidism (SCH) is positively related to depressive symptoms in individuals above 50 years, suggesting it is critical to consider underactive thyroid glands in older patients presenting depressive symptoms. A blood test is also necessary to rule out possible asymptomatic anemia as the cause of the client’s depressive symptoms. Hidese et al.’s (2018) investigation associated iron-deficiency anemia with depressive symptoms among older women.

Assessment:

Mental Status Examination: The client is a 60-year-old black female. The client appears slightly older than her age. The client is well dressed for the occasion, neat, and presentable. The client is cooperative and seems shy and withdrawn. The is of average weight. The client appears stressed and anxious. The client maintains appropriate eye contact, has a steady gait, and seems restless. The client tics in between her speech and touches her hair constantly. However, her speech is clear and coherent. The client is articulate and fluent with an unmarked accent, and slow and soft speech. The client’s mood is “depressed,” affect is anxious, congruent, and labile. The client’s thought process is goal-directed and worrisome. Her perceptions are devoid of auditory and visual hallucinations. The client experiences depersonalization and derealization. She is alert and oriented to her name, place, date, and time. The client does not demonstrate memory impairment. Her attention is typical, insight and judgment are good. She has impaired impulse control and has little motivation for life. The client’s information is reliable and accurate.

Diagnostic Impression: The client’s symptoms meet the diagnostic criteria for recurrent and moderate major depressive disorder and insomnia due to mental illness. According to the DSM5, Major depressive disorder is characterized by depressive mood, diminished pleasure/interest in routine activities, weight loss, psychomotor agitation, worthlessness, suicide ideation, insomnia, and fatigue (American Psychiatric Association, 2020). The client experiences feelings of hopelessness and helplessness, experiences sleep deprivation, and fatigue, and has had weight loss. She equally thought of ending her life, a critical criterion for major depression. As such, the primary diagnosis for this patient could be recurrent and moderate major depressive disorder (Focused SOAP Note and Patient Case Presentation)

Moreover, the client could be suffering from a depressive disorder due to another medical condition. In this case, a condition such as anemia and hyperthyroidism could cause the client’s depressive symptoms (Tang et al., 2019; Hidese et al., 2018). However, this diagnosis is refuted since physical examination showed no hematologic, musculoskeletal, or lymphatic complications associated with anemia or hyperthyroidism.

Reflections: I agree with the preceptor’s assessment and diagnostic impression of the client. I am convinced that the client could be suffering from moderate and recurrent major depression since she presents symptoms of MDD that meet the diagnostic criterion outlined in the DSM5. However, the preceptor’s Insomnia disorder diagnosis could be a comorbid condition. Therefore, the client could be having comorbid insomnia due to a mental disorder. The diagnostic criterion for insomnia disorder includes symptoms such as dissatisfaction with one’s sleep leading to significant distress and impairment of social and critical areas of functioning (APA, 2020). The client complains of not sleeping well at night, and her depressive symptoms may contribute to her insomnia. Widowed women aged 45 and above, lower levels of education, low income, stressful life events, and age are associated with deprivation (Patel, Steinberg, & Patel, 2018). In this case, the client is age and reports experiencing many issues that have impacted her negatively over the past few years. I have learned that the chances of developing depression increase with age and are exacerbated by the perception of an individual’s living environment. I could have done differently including further evaluation of the client’s living environment to determine its role in her depressive symptoms. Moreover, I would have ordered either Zoloft or Trazodone independently since combining these medications can lead to serotonin syndrome, a severe condition characterized by excessive sweating, hallucination, confusion, seizure, blood pressure, or excessive sweating (Scotton et al., 2019)- (SOAP NOTE GERIATRIC EXAMPLE)

Case Formulation and Treatment Plan

The client is to Start Trazodone 50 mg PO daily. The FDA approves Trazodone for major depressive disorder (Shin & Saadabadi, 2017). Although not approved for sleep disorders, Trazodone has been shown to aid sleeping and improve sleeping habits (Shin & Saadabadi, 2017). Discussed the benefits of Trazodone, including its compatibility with other forms of therapy, such as medications or psychotherapies (Shin & Saadabadi, 2017). Discussed other benefits of Trazodone, including the associated lack of addiction. Discussed the common side effects including dizziness, lightheadedness, drowsiness, and mouth dryness. Finally, we discussed the importance of adherence to medication and treatment therapies on clinical outcomes.

The client should commence weekly individual cognitive-behavioural therapy. Individual cognitive behavioral therapy significantly reduces depressive and anxiety symptoms posttreatment (Health Quality Ontario, 2017). Discussed the significance of individual cognitive-behavioural therapy in allowing the client to regain self-worth and its compatibility with other forms of therapy. Discussed the risk of mixing the recommended medications with OTC drugs, substance abuse, or herbal medicine. Discussed the role of substance abuse on mental and physical health and sleeping patterns.

Referrals: Client referred to a psychotherapist for CBT. The client was advised to adhere to the case management and treatment plan.

Return to the clinic: Return after four weeks.

References – SOAP NOTE GERIATRIC EXAMPLE

American Psychiatric Association. (2020). The American psychiatric association practice guideline for the treatment of patients with Schizophrenia. American Psychiatric Pub.

Health Quality Ontario. (2017). Psychotherapy for major depressive disorder and generalized anxiety disorder: a health technology assessment. Ontario health technology assessment series, 17(15), 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709536/

Hidese, S., Saito, K., Asano, S., & Kunugi, H. (2018). Association between iron‐deficiency anemia and depression: A web‐based Japanese investigation. Psychiatry and clinical neurosciences, 72(7), 513-521. https://doi.org/10.1111/pcn.12656

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024. https://dx.doi.org/10.5664%2Fjcsm.7172

Scotton, W. J., Hill, L. J., Williams, A. C., & Barnes, N. M. (2019). Serotonin syndrome: pathophysiology, clinical features, management, and potential future directions. International Journal of Tryptophan Research, 12, 1178646919873925. https://dx.doi.org/10.1177%2F1178646919873925

Shin, J. J., & Saadabadi, A. (2017). Trazodone. https://www.ncbi.nlm.nih.gov/books/NBK470560/

Tang, R., Wang, J., Yang, L., Ding, X., Zhong, Y., Pan, J., … & Chen, Z. (2019). Subclinical hypothyroidism and depression: a systematic review and meta-analysis. Frontiers in endocrinology, 10, 340. https://dx.doi.org/10.3389%2Ffendo.2019.00340

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