Week 3 Assignment: Assessing and Diagnosing Patients with Mood Disorders – Depression SOAP Note Example

Assessing and Diagnosing Patients with Mood Disorders, Depression SOAP Note Example, Week 3 Assignment: Assessing and Diagnosing Patients with Mood Disorders, and Depressive Disorder SOAP Note.

Assessing and Diagnosing Patients with Mood Disorders

Subjective:

Name: Mrs Leslie Tilman, Gender: Female, Age: 32 years

CC (chief complaint): “I can’t sleep much, but that is to be expected.”

HPI: Mrs Tilman presented to the clinic after her husband became concerned about her behavior after delivering her baby two months ago. The patient presents with insomnia and reports having difficulties falling asleep after waking because the baby cries a lot. She also reports feeling terrible, gaining considerable weight, getting upset quickly, and yelling a lot. She also calls a lot and has lost interest in things that used to give her pleasure, like writing, since she hates interruptions but knows the baby will interrupt her. She has also lost her sex drive.

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Past Psychiatric History:

• General Statement: an unremarkable psychiatric history as she has not had a mental check before.
• Caregivers (if applicable): The husband is extremely worried about her behavior since she got a child two months ago
• Hospitalizations: No previous psychiatric hospitalizations
• Medication trials: No medications for psychiatric illness or condition
• Psychotherapy or Previous Psychiatric Diagnosis: Negative for the history of psychiatric diagnosis

Substance Current Use and History:

Denied any drugs or alcohol use

Family Psychiatric/Substance Use History:

Uncle was an opioid user and committed suicide through a gunshot wound (GSW)

Psychosocial History:

Grew up with both parents, and one sister in Omaha, NE. Currently married is a stay-at-home on maternity leave after working in retail for five years. She graduated with bachelor’ in Physics. Previously worked as a research science and high school teacher for five years before giving birth.

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Negative for legal history

Medical History: History of hypertension

• Current Medications: Labetalol 100mg twice daily but admits missing doses  due to forgetting
• Allergies: codeine
• Reproductive Hx:12 years age at menarche, reports normal menstrual pattern in terms of cycle length, duration flow, and amount of flow but is not having periods, as she is breastfeeding. She is not on the pill. Other reproductive history is unremarkable

ROS:

• GENERAL: T-97.6 P 97 R 22 BP 149/98 Ht 5’3 Wt. 245lbs BMI 43.4 Denies fever or chills Reports weight gain after pregnancy
• HEENT: Denies head injury, denies diplopia or blurred vision, or any vision changes. Prohibits pain or loss of hearing in the ears; reports no discharge. No nasal congestion or discharge. Denies throat or neck pain. Denies difficulty swallowing, and no hoarseness.
• SKIN: No rashes or pruritus, no changes of colouration or jaundice
• CARDIOVASCULAR: No chest pain, no orthopnea, or paroxysmal nocturnal
• RESPIRATORY: No dyspnea ho egophony, breath sounds present and clear bilaterally on auscultation
• GASTROINTESTINAL: No mass or hernia was observed. On auscultation, bowel sounds were present in all four quadrants. The abdomen is soft and non-tender
• GENITOURINARY: Denies hematuria, denies difficulty starting or stopping the stream of urine
• NEUROLOGICAL: headache, denies history of tremors or seizures
• MUSCULOSKELETAL:  Denies hearing snapping or clicking sounds, denies falls or  pain
• HEMATOLOGIC: No known blood or clotting disorders
• LYMPHATICS: No lymphadenopathy
• ENDOCRINOLOGIC:  No known diabetes or thyroid condition

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Objective:

Physical exam: if applicable

Mrs Tilman appears distracted, overweight and is irritable

Diagnostic results:

Urine drug screen- negative for cocaine

Random blood sugar test A1C test below 5.7% and glucose tolerance test 139mg/dL

The thyroid blood test TSH range was 3.6 mIU/mL

Assessment:

Mental Status Examination: An average patient can respond to stimuli as an individual without neurological abnormality.

Concentration is lowered, guilt is present, appetite increased( evidenced by weight gain), sleep disturbance, psychomotor agitation making her upset easily, death or suicidal ideation but not acted upon, interest in writing decreased, energy to energy in weight-reducing exercises decreased (i.e., C GASP DIE) significant for depression

Differential Diagnoses:

Depressive Disorder

Mrs Tilby presents with symptoms significant for major depressive disorder. MDD is considered because She exhibits several symptoms that comprise the mandatory five or more of the DSM-5 Criteria for Major Depressive Disorder(Park& Zarate, 2019) lasting over two weeks. These symptoms include having a depressed mood most of the day as reported in the subjective information she gives, like feeling sad and hopeless or the observations others make as if she appears tearful. The patient also diminished interest and pleasure in activities that used to give her pleasure before. She also reports not having a sex drive and repulses intimate advances by her husband. These include writing which she admits she would do but cannot do nowadays since the baby is bound to interrupt her. The third symptom is that she has trouble sleeping, and even when baby Jesica cries, she wakes up and has difficulties falling asleep again. She also reports weight gain immediately after falling pregnant, and besides psychomotor agitation, she has feelings of guilt. Suicidal ideation, although not acted upon, also presents itself amongst others.

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 Postpartum Depression

The woman has several symptoms of post-partum depression. These include mood swings, sadness, irritability, crying, trouble sleeping and feeling overwhelmed. Had they lasted for a few days, they would have passed for baby blues. However, that has continued well into the second month since delivery making postpartum depression a healthy option. The symptoms develop within the first few weeks of giving birth but could have started before birth. In addition to the baby blue symptoms, the patient fears she is not a good mother, and feels guilt, amongst others (Batt et al., 2020). Be that as it may, the woman admits the baby did not trigger her disinterest in sex is coming into the picture and admits that even before the birth, her social life was non–existent. This admission means that withdrawing from family and friends had happened long before Jessica’s birth, probably even before her conception. The duration of the symptoms and their onset should help rule out postpartum, as do the absence of organic causes since no other illness is present. The same criteria should rule out physiological causes like an overactive thyroid gland to blood sugar imbalances.

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Side effects of skipping the prescribed antihypertensive drugs

Kessing et al. (2020) note that depression could be a side effect of nonadherence to prescribed antihypertensive drugs. The patient admits to skipping due to forgetfulness sometimes. This nonadherence would, besides causing depression, means the woman’s blood pressure is poorly controlled, but this is not the case here(Jani et al., 2016). As such, the manifesting depression could be caused by skipping the medication prescribed.

Reflections

 Psychiatric and mental health nurse specialists are aware that depression is a condition that disables the individual at the social and physical level related to poor self-care, increased mortality, risk of suicide, and adverse medical outcomes. One is bound to experience an ethical dilemma about self-management that involves training, skill acquisition, and therapeutic interventions through which patients diagnosed with depression are taught how to care for themselves and manage their own lives and illnesses. Bipeta (2019) notes that the Mental Health Care Act 2017) explicitly outlines patients’ rights diagnosed with mental illness. That means that I would have to factor in these rights and translate them into ethics of psychiatric care concerning respect for autonomy, the principle of non-maleficence, beneficence, and justice. Other ethical issues to consider would be boundary violations of informed consent and confidentiality. In a moral dilemma, I would urge the community healthcare system to build commitment and trust. These attributes would help increase reflections and ethical discussions in the community setting, especially when caring for depressed mothers taking care of their infants.

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References

Batt, M. M., Duffy, K. A., Novick, A. M., Metcalf, C. A., & Epperson, C. N. (2020). Is postpartum depression different from depression occurring outside of the perinatal period? A review of the evidence. Focus, 18(2), 106-119.

Bipeta, R. (2019). Legal and ethical aspects of mental health care.

Jani, B. D., Cavanagh, J., Barry, S. J., Der, G., Sattar, N., & Mair, F. S. (2016). Relationship between blood pressure values, depressive symptoms, and cardiovascular outcomes in patients with cardiometabolic disease. The Journal of Clinical Hypertension, 18(10), 1027-1035.

Kessing, L. V., Rytgaard, H. C., Ekstrøm, C. T., Torp-Pedersen, C., Berk, M., & Gerds, T. A. (2020). Antihypertensive drugs and risk of depression: A nationwide population-based study. Hypertension, 76(4), 1263-1279.

Park, L. T., & Zarate Jr, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559-568.

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