Number Practice 6665 6675: Focused SOAP Psychiatric Evaluati

Nrnpprac 6665 6675 Comprehensive Focused Soap Psychiatric Evaluatio

The assignment involves conducting a comprehensive focused SOAP psychiatric evaluation based on a detailed case presentation. This includes documenting subjective complaints, history of present illness, substance use, past medical and psychiatric history, review of systems, objective findings, diagnostic results, mental status examination, assessment, case formulation, treatment plan, and reflections. The focus is on accurately capturing clinical details, formulating diagnoses, and proposing appropriate treatment strategies, supported by scholarly references.

Paper For Above instruction

Psychiatric evaluations are vital tools in mental health assessments, providing clinicians with a structured framework to gather, analyze, and synthesize patient information. They facilitate understanding of complex psychiatric presentations, guide diagnosis, and inform treatment planning. This case involves a 62-year-old male presenting with major depressive disorder (MDD), complicated by recent grief and suicidal ideations following the loss of his wife. The comprehensive psychiatric SOAP note captures the critical facets of his clinical picture.

Subjective

The chief complaint (CC) expressed by the patient is feelings of helplessness and suicidal ideation following his wife’s death two months prior. He states, “I have been feeling helpless since my wife passed two months ago, and I want to commit suicide because I am too lonely.” The history of present illness (HPI) reveals that his symptoms began after the tragic loss of his wife, who was his sole companion. He reports persistent feelings of hopelessness and loneliness, with passive thoughts of joining his wife in the afterlife. He admits to increased alcohol consumption—up to three bottles of beer daily—to aid sleep, deviating from his previous use of alcohol twice weekly. He smokes five cigars daily and occasionally smokes cigarettes. His medical history includes Type 2 diabetes managed with metformin 500 mg twice daily, with occasional missed doses.

Review of Systems (ROS)

• General: Reports weight loss, no fever or chills.
• HEENT: No head trauma or headache, reduced hearing, no eye pain, complains of missing teeth and erythematous bruising around the neck from a previous suicide attempt.
• Skin: Wrinkled with bruising.
• Cardiovascular: No palpitations or chest discomfort; normal heart rate and rhythm; reports shortness of breath on exertion.
• Respiratory: Slow, steady respirations; denies dyspnea.
• Gastrointestinal: Reduced appetite, diminished bowel sounds, bowel movement two days prior.
• Genitourinary: No concerns, recent prostate exam.
• Neurological: Reduced sleep, no headaches or seizures.
• Musculoskeletal: Mild joint stiffness without pain.
• Hematologic: No bleeding disorders.
• Lymphatics: Swollen and tender cervical lymph nodes.
• Endocrinologic: No extreme thirst or hunger reports.

Objective

Diagnostic testing was not performed at this visit. The clinical presentation, however, reflects significant depressive and grief-related symptoms.

Assessment

Mental Status Examination (MSE):

The patient is a well-oriented 62-year-old male who appears his stated age. He is appropriately dressed, with unkempt gray hair, and has a generally sad affect aligning with his mood report. His speech is clear with a low tone. Thought process is logical and goal-directed; no evidence of flight of ideas or loose associations. He displays poor insight into his condition but retains good concentration. Memory is intact. He denies visual or auditory hallucinations but reports suicidal ideations with a plan to harm his pets before self-harm.

Diagnostic Impression:

• Major depressive disorder (MDD): Characterized by persistent sadness, hopelessness, anhedonia, sleep disturbances, appetite changes, and suicidal ideation, fitting DSM-5 criteria (American Psychiatric Association, 2013). The recent grief likely exacerbates these symptoms.
• Adjustment disorder with depressed mood: Considered but less probable due to severity and suicidal intent.

Reflections

This case underscores the importance of early intervention and comprehensive assessment. Recognizing the profound impact of grief on mental health is critical. Often, mental health issues such as depression can relapse or worsen when compounded by stressors like loss. Evaluating past psychiatric history would enhance treatment planning, as some episodes of depression are recurrent. Addressing stigma around mental health and fostering open communication is essential for effective care.

Case Formulation and Treatment Plan

• Pharmacotherapy: Initiate fluoxetine 20 mg daily to manage depressive symptoms, considering evidence of efficacy in late-life depression (Micheli et al., 2018).
• Psychotherapy: Referral for cognitive-behavioral therapy (CBT) or group therapy to develop coping strategies (Weck et al., 2015).
• Safety planning: Provide emergency contact numbers and safety plan to address suicidal ideation.
• Follow-up: Re-evaluate in two weeks to assess response and medication tolerability.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Chand, S. P., & Marwaha, R. (2022). Anxiety. StatPearls Publishing.
• Micheli, L., Ceccarelli, M., D’Andrea, G., & Tirone, F. (2018). Depression and adult neurogenesis: positive effects of the antidepressant fluoxetine and physical exercise. Brain Research Bulletin, 143, 234-242.
• O'Donnell, M. L., Alkemade, N., Creamer, M., et al. (2016). A longitudinal study of adjustment disorder after trauma exposure. American Journal of Psychiatry, 173(1), 65-72.
• Weck, F., Gropalis, M., Hiller, W., & Bleichhardt, G. (2015). Effectiveness of cognitive-behavioral group therapy for health anxiety. Journal of Anxiety Disorders, 30, 1-7.
• World Health Organization. (2020). Depression. WHO. https://www.who.int/news-room/fact-sheets/detail/depression