SOAP Note-Mood Disorders essay
SOAP Note-Mood Disorders essay
Subjective Data
Chief complaint: “my mum is worried because I become moody every year around this time” SOAP Note-Mood Disorders essay
History of presenting complaint: Ms. Natalie is a 17years old female sent to the clinic due to her mum’s worry about mood changes. She says that she feels so down and she is not doing well in school. She is worried because she has suddenly changed her interest in the course work of special business program. Moreover, she finds it difficult to complete tasks. She states she has reduced concentration span, impaired memory, increased need for sleep, weight gain, feels miserable about herself, and finds her friends and the current season annoying. She denies hallucinations, delirium, and suicidal ideation.
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Psychiatric history: the patient denies depression, anxiety, psychosis, and substance abuse disorder.
Substance use history: she denies the use of marijuana, alcohol, tobacco, cocaine, and other hard drugs.
Family history: she grew up with her parents and four siblings. She denies a family history of chronic diseases.
Social history: the patient is single. She was born and raised in New Orleans. She recently accelerated the high school business program. She is living in a specialty high school campus dormitory as a student and working part-time at a coffee shop. SOAP Note-Mood Disorders essay
Past medical and surgical history: the patient denies surgical procedures, hospital admission, previous chronic diseases, and transfusion. Her immunization schedule is up to date.
Allergies: she denies food and drug allergies
Review Of Systems
General: Ms. Natalie Crew denies headache, fatigue, weight loss, night sweats, chills and rigors, and fever.
HEENT: The patient denies headache, dizziness, running nose, nasal congestion, throat pain, neck swelling, ear ache, tearing, blurring of vision, and loss of hearing.
Respiratory system: the patient denies coughing, running nose, chest pain, wheezing, tachypnea, difficulties in breathing, sputum production, and respiratory distress.
Cardiovascular system: the patient denies chest pain, syncope, shortness of breath, palpitations, tachycardia, orthopnea, paroxysmal nocturnal dyspnea, dyspnea, and swelling of lower limbs.
Gastrointestinal system: the patient denies abdominal pain, reflux, heartburn, loss of appetite, nausea, vomiting, diarrhea, constipation, and GERD.
Genitourinary system: the patient denies dysuria, hematuria, polyuria, anuria, incontinence, urgency, per vaginal discharge, and itchiness.
Musculoskeletal system: the patient denies muscle pain, joint pain, muscle spasm, muscle weakness, and stiffness.
Neurological system: she denies facial droop, tingling sensation, muscle weakness, numbness of extremities, and sciatica.
Hematological system: she denies anemia, fever, bleeding tendencies, dizziness, and recurrent infections.
Endocrine system: the patient denies heat and cold intolerance, stretch marks, and fatigue.
Skin: she denies itchiness, rash, erythema, hypopigmentation, and hyperpigmentation.
Objective Data
General examination: The patient is alert, calm, and seems overweight. She has no pallor, jaundice, or cyanosis.
HEENT: the head is round with no mass, swelling, or scar. The eyes are clear and moist. The nose is intact without scars and erythema and the mucus membrane is moist. The ears have no scars, swelling, wax impaction, and discharge, the mouth is pink and moist with no swollen tonsil gland.
Respiratory system: the chest expands symmetrically when breathing. There is no intercostal resection, lower chest wall indrawing, and use of accessory muscles when breathing. There is no mass and scar on the chest wall. There is a resonant percussion note and vesicular breath sounds on auscultation. There are no rhonchi, stridor, or crackles.
Cardiovascular system: the heart is at 5th ICS MCL. The peripheral pulses are present with normal volume, regular rhythm, and rate without bruits. The heart sounds S1 S2 is present without murmurs, parasternal heaves, and thrills.
Abdominal examination: the abdomen is round with a normal contour. The bowel sounds are present in the four quadrants and there is a tympanic percussion note. There is no shifting dullness and organ enlargement.
Neurological system: the patient is alert and oriented to time, place, and person. She can obey commands. She assumes an upright gait and posture. Her cerebellum functions are intact. The cranial nerves are all functional.
Diagnostic investigations: there are no specific tests that can confirm the diagnosis in this patient. However, some underlying diseases like sepsis, hypothyroidism, chronic kidney disease, liver failure, and substance abuse may alter mental function (Jacobson, et al, 2019). Therefore, I would request various tests to rule out the cause of the disease. The tests include a complete blood count with differentials, thyroid function test, liver function test, renal function test, and blood and urine toxicology screen. According to Wang, et al, (2019), screening tests specific to this patient are the PHQ-9 questionnaire of depression scale, Beck Depression Inventory, the young mania rating scale, and Assess MD adult depression assessment.
Assessment
Mental State Examination
The patient is alert and oriented to time, place, and person. She is neat for the occasion and weather. She has reduced gestures, does not maintain eye contact, and fidgets during the interview. She is in a low mood pessimist about the present and hopeless about the future. Her speech is slow with long pauses and has a low volume. Her concentration and memory are intact during the interview. Her thought process is congruent without hallucination and suicidal thoughts. Her judgment and insight are intact.
Differential Diagnoses
- Hypomania bipolar F31.0
- Major depressive mood disorder F32.9
- Dysthymic mood disorder F34.1
Hypomania bipolar is a mental disorder presenting with low mood, hypersomnia, agitation, fatigue, hopelessness, excessive guilt, loss of concentration, indecisiveness, and diminished interest or pleasure. These symptoms manifest after an episode of excitement, increased distractibility, diminished need for sleep, flamboyance, and inflated self-esteem (Carvalho, et al, 2020). Causes of hypomania bipolar are depression, genetics, stressful events, herbal supplements, and change in sleeping patterns. This is the primary diagnosis because the patient presents with low mood, loss of interest in her studies, irritability, excessive guilt, and inability to complete tasks. These symptoms occurred after a season of enjoying her studies, meeting her friends, and going out to the beach. The patient’s mood changes were due to seasonal changes from summer to winter. She prefers summer to winter because she can go to the beach. SOAP Note-Mood Disorders essay
Major depressive mood disorder is a mental illness characterized by agitation, mood changes, and irritability. These psychomotor changes affect social interactions and cognitive functions. According to the American psychiatric association DSM-5 criteria, the patient must present with loss of interest, hopelessness, suicidal ideation, fatigue, loss of memory, and impaired concentration (Vidal, et al, 2020). The patient’s mood changes have been affected by performance, lost interest in her school work, and can hardly complete tasks. However, it is not the actual diagnosis because the patient denies suicidal ideation.
The dysthymic mood is a chronic depressive mood persisting from childhood. It presents with anger outbursts, sadness, loss of memory, inability to concentrate, suicidal attempts, and poor judgment (Carta, et al, 2019). This is not the actual diagnosis because the patient’s symptoms are acute and have no suicidal ideation.
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Reflection
Assessing a patient with a mood disorder was initially challenging because it was hard to create rapport to share their problem. During the interview, the patient takes long pauses and has a slow speed, low tone, and low volume. In the future, I will establish a good patient rapport by ensuring there is a comfortable sitting position and the office maintains privacy. I will welcome the patient and begin catching up with them before asking about their problems. I will ensure the catchup is easy and interactive around their lives. Then I will select the appropriate words to ask the patient what is wrong with them. I will listen actively and maintain genuine gestures and cues. I will ask open-ended questions to allow the patient to express their concern.
Mood disorders are mental diseases because they disrupt the cognitive and behavioral functions of a patient. Therefore, these patients have a right to protection from harm, right to treatment, right to confidentiality, and right to informed consent (Sapthiang, et al, 2017). As a nurse, I will incorporate the ethical principles of consent, beneficence, and confidentiality when treating this patient. She is 17years, her insight and judgment are intact, and she is alert. I will obtain informed consent before treatment because she understands the course of the illness and can make the appropriate decision. The patient has a right to the confidentiality of her medical information and chooses who to disclose her information. She has the right to quality treatment to restore her functions and improve her quality of life. The patient is a full-time student working part-time, she will seek medical help to restore her functionality. Being a student, she is aware of mental instabilities and their impact. Moreover, she has a part-time job, therefore, she has income and social protection and can access healthcare services of decent quality. SOAP Note-Mood Disorders essay
