WeeK-4 Soap note
Assignment Details ( you can also use your imagination in addition to given information below, if specific information is not given)
Jill is a 50-year-old woman who lives with her husband and two children (aged 20 and 18). She has come to see her PMHNP with worries about a number of health problems including extreme tiredness, agitation and pains in her chest. Past history Jill has been a frequent attender at the practice over the years, often with concerns about her or her children’s health. She experienced postpartum depression with her second child. She has a history of GAD and Depression and has been on and off antidepressants for the past 30 years. When she was 23 she took an overdose following the break-up of a relationship. She had some sessions of counseling about 10 years ago that she found helpful. She was referred to a primary care mental health worker in the practice 2 years ago for help with anxiety and low mood. She had some sessions of individual guided self-help, but she found that this made no difference. She was put in touch with a voluntary sector self-help group for people with anxiety around this time – but did not pursue this. She has no other health history or complaints today related to medical health, no military history. She currently takes no medications and has no allergies. She considers herself healthy as she eats a vegan diet and does walk 2 times a week around the local lake.
On examination Jill says she has always been a very ‘nervy’ person who finds dealing with everyday stresses difficult. She worries a lot about herself and her family and easily gets ‘in a state’ and assumes ‘the worst’ – for example, if family members are unwell or if they are late coming home. Sometimes things get so bad that she needs someone around her constantly to reassure her and feels that she can’t be left on her own. The intensity of these problems has varied over the years, but has become worse again during the past 8 months following her husband’s diagnosis of heart problems. She has been drinking wine most evenings to try to calm herself down. More recently things have become so bad that she has sometimes felt that if she were left on her own she might harm herself. Her family has been very supportive and stayed with her during these periods until she calmed down, but is now finding this difficult to manage. Last night she had an extended period of feeling like everyone would be better off without her. She describes a plan “to drink alcohol, take some of her husband’s pain medications, start her car in the garage and pass out.” She states the only thing that ever helps her is to walk and hum to herself and in the winter she sometimes knits.
Vitals:
BP: 122/68
HR: 74
R: 18
T: 97
O2: 99%
Pain: 2 on 0–10 scale
Wt.: 147
Ht.: 66”
Direction
Read the case study, complete an initial assessment soap note and develop a safety plan for Jill. Add a short narrative about educating the family and patient about safety of environment and coping strategies to help the patient through any times involving suicidal thoughts or thoughts of self-harm. Consider if she should be admitted for monitoring or scheduled for more frequent follow-ups, what type of psychotherapy modality would be helpful, et cetera.
Use the SOAP Note template located under Course Resources to complete the assignment.
Please write
• Initial SOAP note ( SEE ARTACH TEMPLET FOR SOAP note)
• develop a safety plan for Jill
• provide education about safety and coping strategy include family member
• Develop good safety plan for Jill
• Develop follow- up plan including psychotherapy modality
• Use at list 4-5 definite and 3-4 differential diagnosis
Please use at list 3 references
S: 50-year-old female presents with concerns about extreme tiredness, agitation, and chest pains. Has a history of GAD and Depression and has been on and off antidepressants for the past 30 years. Experienced postpartum depression with second child. Has a history of suicide attempt by overdose at age 23. Reports increased stress and anxiety related to her husband’s recent heart problems. Has reported recent thoughts of self-harm and suicide.
O: Vital signs are within normal limits. The patient reports feelings of nervousness and anxiety that have become exacerbated in recent months due to her husband’s health problems. She reports difficulty managing stress and often needs someone around her to reassure her. She reports using alcohol to cope and has a recent increase in suicidal thoughts and plans.
A:
Definite Diagnosis:
Generalized Anxiety Disorder (GAD)
Depression
Suicidal Ideation
Substance Use Disorder (Alcohol)
Acute Stress Disorder
Differential Diagnosis:
Panic Disorder
Adjustment Disorder
Bipolar Disorder
Post-Traumatic Stress Disorder (PTSD)
P:
Safety Plan: The patient should be advised not to drink alcohol and to keep all medications, including pain medications, out of reach. She should also be advised not to be alone for extended periods of time and to reach out to a family member, friend, or healthcare provider if she feels overwhelmed or has thoughts of self-harm.
Follow-up Plan: The patient should be scheduled for more frequent follow-ups with her PMHNP and referred for a psychiatric Assessment. She may benefit from a combination of medication and psychotherapy, such as cognitive-behavioral therapy (CBT) or dialectical behavior therapy (DBT). The patient and her family should also be educated on coping strategies and resources available for support.
Education: The patient and her family should be educated on the dangers of self-harm and the importance of seeking help if thoughts persist. They should also be provided with resources such as the National Suicide Prevention Lifeline (1-800-273-TALK) for immediate support. The patient should also be encouraged to engage in activities that bring her joy, such as walking and knitting.
R: Further Assessment and management is necessary to address the patient’s ongoing mental health concerns and to ensure her safety. (References: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC: American Psychiatric Publishing. National Institute of Mental Health. (2021). Substance Use Disorders. Retrieved from https://www.nimh.nih.gov/health/topics/substance-use-disorders/index.shtml National Alliance on Mental Illness. (2021). Suicide and Mental Illness. Retrieved from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Suicide)
