Discussion A Questions 1.) Given her arthritis and limitations in physical activity, what coping strategies can the patient utilize to alleviate her anxiety and depression? 2.) Which antidepress

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (9): SOAP note

Jasleen Tuli

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Professor Evenson

July 24th, 2024

Subjective:

CC (chief complaint): “ I have hard time with sleeping, nothing seems to work”.

HPI: This is a 65 year old married female who came to the clinic for her initial evaluation. She states “ I have sleeping issues”. Pt reported that her previous psychiatric clinic has closed down which has led her to finding this clinic. She mentions that she is only sleeping about 5 hours per night, she reports that without Benadryl, she is sleeping about 3 hours per night. She mentions that she is currently retired and doesn't have much to do around the house. Her husband is also home all the time, which is new for her since they retired about two months ago, she reports becoming easily frustrated at him. She feels depressed and lonely due to the lack of social interaction and not have the set routine. Previously, she worked as a hospital clerk, a busy job that allowed her to socialize and form friendship at work. She also recently been diagnosed with arthritis about 2 months ago. Since retiring, she has experienced sleep issues, worsened anxiety- described as “ being worried about everything, thinking the worst out of the situations”, and depression. She constantly worries about her family, feels restless, and rates her anxiety as 6 out of 10. Additionally, she feels sad, finds little enjoyment in life, and intermittently experiences hopelessness and helplessness, rating her depression as 8 out of 10. To alleviate her depression, she tries to exercise and go for evening walks with her neighbors, though this depends on her mood and her pain level.She reports that she wishes to be more active however the pain related to the arthritis hinders her from doing some of the activities that she would otherwise enjoy such as camping. She denies having any short-term or long-term memory deficits or mood swings. Previously diagnosed with depression about 8 years ago, she was prescribed trazodone and Wellbutrin by her past psychiatrist last year. She wants to improve her sleep, hoping it will reduce her depression. However, she reports that trazodone makes her feel groggy- felt like “ zombie”, affecting more than half of her day.She reported that she stopped trazodone “ about 4-5 months ago” and instead has been taking Benadryl 25mg at bedtime. She has tried couple antidepressants in the past and doesn't like how some of them made her feel, noting that she feels sensitive to medications.She reports that Wellbutrin hasn’t helped her much and believes that her anxiety has worsened slightly with this medication. She reports low interest in activities and feels guilty about not spending time with her children when they were growing up, missing significant events due to work commitments to maintain financial stability. She experiences low concentration and fluctuating appetite but denies any recent weight changes and appears to be of average weight. She denies experiencing auditory, visual, olfactory, or tactile hallucinations, as well as any paranoia. However, she admits to feeling easily frustrated but denies any impulsive behavior or grandiose thoughts. She experiences racing thoughts.She denies any flight of ideas. She reports being in therapy in her early 20’s.She denies any self-harm behavior,and denies any suicidal attempts. Pt denies any current suicidal ideations, and homicidal ideations. She agrees to a safety contract. Pt report’s that she went to her PCP about 3 months ago and her labs were within normal range.

Substance Current Use:

Past: Marijuana, stopped heavy alcohol usage about 6 years ago. Current: intermittent alcohol drinks on occasional social events, max 1 or 2 mixed alcohol drinks. Caffeine- usage- 3-4 cups of coffee daily, denies any soda usage. Denies using smoking cigarettes.

Medical History:

High cholesterol, Hypothyroidism, Arthritis, donated one kidney about 8 years ago.

Current Medications: Trazadone 50mg and Wellbutrin XR 150mg daily.
Past Medications: Effexor- blood pressure , Lexapro- caused GI symptoms, Benadryl- dry mouth and dizziness.
Allergies: NKA

Reproductive Hx: She has been pregnant four times and currently has three living children. She had one abortion around the age of 22. She went through menopause at age 56 and denies any reproductive illnesses.

Past Psych Dx: Depression diagnosed about 10 years ago.

Family Psych Hx: Mother had Depression. Alcohol abuse is excessive in her family including uncles, aunts and her brothers.

Psychiatric Hospitalization: Denies

Social History: She was born and raised in California by her biological parents. Her mother is alive, her father passed away in a car accident about 10 years ago. She has 1 older brother and 1 younger sister and she shares a good relationship with them. She has been married twice and reports that her current relationship with her husband is good.She has 3 childrens and 1 grandchild. She shares a good relationship with her childrens. She currently lives in a one story house. She reports feeling safe in the relationship. She had taken some college classes and is currently retired from a clerk job at the hospital. She reports that her financial support is her social security and her husband’s pension. Her social support is her friends and family. Her hobbies include walking and playing golf.

Beliefs: She believes in higher power and practices Christianity.

Trauma: People misjudging her – especially her childrens, which created a lot of drama at home in the past. She was sexually assaulted at the age of 21 years old while she was at her friends birthday party. She reports that she was in therapy for that. She denies any witnessed trauma.

ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: Skin appears to be intact, no hyperpigmentation, no lesions, no open wounds reported
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations or edema.
RESPIRATORY: Does not report difficulty breathing, no cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain
or blood.
GENITOURINARY: No burning upon urination, no hesitancy. No foul odor and no odd color.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or
tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Muscle pain in joints reported. Noted to be steady gait.
HEMATOLOGIC: Denied any reports of anemia or easily bruising.
LYMPHATICS: No enlarged nodes reported.
ENDOCRINOLOGIC: Hypothyroidism history. No reported polyuria and polydipsia.

Objective:

Diagnostic results:

Order a complete blood count (CBC) and comprehensive metabolic panel (CMP) to assess the patient's overall health, organ function, and to rule out potential infections. Additionally, a thyroid function test is necessary as the patient has hypothyroidism, which can contribute to depressive symptoms (Smith et al., 2020).A urinalysis is also recommended given the patient's history of alcohol abuse. It's important to confirm that the patient is not currently abusing alcohol, especially since her depression symptoms have recently worsened (Brown et al., 2021). Evaluating kidney function is crucial, particularly because the patient has only one kidney. Ensuring kidney function is preserved is vital since medications can further damage it (Johnson et al., 2022).Measuring HgbA1c is essential to determine if the patient has diabetes, as pt had reported diabetes on her paternal side of the family, managing blood sugar levels is important for overall health (Williams et al., 2023).Pt is also diagnosed with high cholesterol levels. High cholesterol can itself can increase the risk of cardiovascular diseases.

Assessment:

Mental Status Examination: Patient is Alert and oriented x 4. Pt’s grooming and hygiene appears to be clean. Pt appears to be normal weight. Pt’s mood is noted to be depressed, cooperative upon approach. Speech: fluent, clear and normal volume. Pt denied having any auditory, and visual hallucination. No tactile or olfactory hallucinations reported either. Pt is noted to have impaired concentration. Affect is anxious and sad and is congruent to throught content. Short term and long-term memory are noted to be intact. No evidence of abnormal motor activity. Insight and Judgement are intanct. She denied any suicidal and homicidal ideations.

Diagnostic Impression:

Major depressive disorder, recurrent, moderate (F33.1): Patient has a documented history of major depressive disorder (MDD) spanning eight years and has undergone few pharmacological treatments with antidepressants. Over the past two months, the patient has experienced a notable exacerbation in depressive symptoms. She reports a pervasive low mood, feelings of sadness and hopelessness. Additionally, she experiences significant insomnia, averaging only 4-5 hours of sleep per night, accompanied by a marked decrease in energy, impaired concentration, and pervasive feelings of guilt. A recent study highlights the recurrence and persistence of depressive symptoms despite treatment, emphasizing the importance of monitoring changes in mood and functional impairments over time in patients with a chronic course of MDD (Severe et al.,2020). Furthermore, research explores the interplay between insomnia and depressive symptoms in patients with MDD, indicating that insomnia often exacerbates other symptoms such as fatigue, poor concentration, and feelings of guilt, thereby complicating treatment outcomes (Fang et al.,2019)

Insomnia (F51.01): The patient has a longstanding history of insomnia, characterized by difficulty both falling asleep and maintaining sleep, resulting in only 3-5 hours of sleep per night. The patient denies taking naps during the day and reports that this condition has significantly impaired her daily functioning and relationships. She has been experiencing these symptoms for over a year, with a noted worsening recently. Despite being retired and having ample time to relax, she remains unable to sleep adequately. She also attributes feelings of sadness to her lack of sleep. Research supports that insomnia can significantly impact mental health and daily functioning. Irwin et al. (2022) identified insomnia as a risk factor for the onset of depression in the elderly, underscoring the potential mental health implications of chronic sleep disturbances. Additionally, Patel et al. (2018) highlighted the pervasive impact of chronic insomnia on overall health, emphasizing the importance of addressing sleep issues to improve quality of life as individuals with insomnia are 23 percent more likely to experience depressive symptoms.

Adjustment disorder with mixed anxiety and depressed mood (F43.23): pt reported that her recent retirement has led to increased time at home, resulting in social withdrawal and heightened irritability towards her husband. This shift has hindered her ability to communicate and socialize effectively. Additionally, her arthritis has restricted her from engaging in outdoor activities like camping, further exacerbating her feelings of depression. She describes a pervasive sense of worry and unease, compounded by the lack of routine and social interaction. Recent research underscores the multifaceted nature of adjustment disorder, emphasizing that significant life changes, such as retirement, can precipitate symptoms of anxiety and depression (Lahdenpera et al.,2021). It is to be noted that chronic illness and reduced physical activity can contribute to the worsening of depressive symptoms in retired individuals. Although, retirement may be something an individual may look up to, however the impact of social isolation and the loss of daily structure on mental health, particularly among older adults can lead to depressed mood.

Reflections:

I agree with the preceptor’s assessment. It appeared that the patient was experiencing worsening depression and anxiety, which began after she left her job. She had previously been diagnosed with depression about 8 years ago.These symptoms seemed to arise because she spent more time at home, lacked social interaction, and did not have as much communication with her family as she would have liked. Her insomnia likely exacerbated these feelings, as sleep significantly affects mood and can deteriorate mental health. I learned that a thorough assessment is crucial in diagnosing and treating patients, and it is important to ask if they are open to different medications. In my experience, some patients may come to the clinic but are reluctant to try new medications due to previous adverse effects. If I had more time during the assessment, I would have used the PHQ-9 and GAD-7 scores to evaluate the severity of her depression and anxiety. The patient mentioned receiving therapy around the age of 20, but it was not discussed how long she had been in therapy or if she had used any medications during her 20’s when she had suffered from sexual trama.Reflecting further, there are significant legal and ethical considerations in the care of this patient beyond confidentiality and consent. Given the age of over 65 years, there is a heightened need to assess for elder abuse and neglect, which are legal requirements for healthcare providers. Fortunately, pt did not exhibit any signs of the abuse in this case.Ethically, it is important to consider her autonomy and ensure that she is actively involved in decision-making about her treatment plan. The social determinants of health play a crucial role in this patient's condition. Her recent retirement likely affects her financial stability. Social isolation, as indicated by her limited interaction with others, can further deteriorate her mental health. Promoting health and preventing disease in this context involves not only treating her current symptoms but also addressing these broader social factors. This might include connecting her with community resources for social support, financial assistance programs, church programs and setting her up with therapist.Considering her medical history (PMH) and other risk factors, it is important to monitor for comorbid conditions that are common in older adults, such as cardiovascular disease or diabetes, which can complicate her psychiatric symptoms.Providing education on lifestyle modifications, such as exercise and diet, can help in disease prevention and health promotion. Encouraging regular physical activity, for instance, can improve both her physical and mental health, reducing symptoms of depression and anxiety.Overall, a holistic approach that considers her medical, psychological, social, and ethical dimensions is essential in managing health effectively.

Case Formulation and Treatment Plan:

Based on the patient’s presentation, it is evident that pt is experiencing worsening depression along with feeling of emptiness and lonely. Pt reports that trazodone was not working well for her and she had stopped it about 4-5 months ago, she has been on Benadryl, however she reports dry mouth and feeling dizzy at night time and acknowledges that it is not a medication that is meant specifically for sleeping. Pt also reports that she was started on Wellbutrin about a year ago, however she believes that it hasn’t helped her much. Initially, pt was bit resistant to trying any new antidepressant as she primarily sought help for sleeping . She reported that she is scared of side effects. The patient was educated about depression and informed about the side effect profiles of SSRIs and SNRIs. She was given instructions on how to manage any side effects if they occur and was provided with information on the positive effects of these medications, including their role in mood elevation.Pt was agreeable to starting on new medications. Pt was started on sertraline 25mg PO daily for depression and anxiety. Nothing, that pt only has one kidney, sertraline does not have much effect on the kidneys but does need to have lower dosage if patient has hepatic impairment. For sleeping, pt was prescribed Suvorexant 10mg at bedtime. It has been futher emphasized that suvorexant is one of the safest medication that can be prescribed to elderly adults and it has proven to show effective results with individuals experiencing insomnia (Tampi et al.,2018). Pt was informed regarding the side effects of the medication and was also informed to have night light in the room as it can cause dizziness. The reason behind choosing the medication instead of nonpharmacological methods was because pt had already tried changing the bed time routine and playing the white noise to help her fall asleep. It was also discussed with the pt to not abruptly stop the medication and if she does experience the side effects, pt is to contact the office. Pt also informed that some of the common side effects do tend to subside within 1-2 weeks however if it remains bothersome, change in medication can be made. Both of the medication have the least weight gain profile to them, it is important as pt had reported high cholesterol. Given the patient’s depression and new adjustment to being at home, therapist was recommended. Pt was also informed to avoid drinking alcohol while being on the medication. The patient was provided with the clinic's contact information as well as emergency services numbers (911 or 988) for crisis situations. Additionally, I would request any available lab results from the patient’s primary care provider and gather more detailed information on their medical history and previously prescribed medications. The assessment with the patient lasted one hour. A follow-up appointment was scheduled for one month later to monitor symptoms.

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

Discussion Questions

Given her arthritis and limitations in physical activity, what coping strategies can the patient utilize to alleviate her anxiety and depression?
Which antidepressant do you believe works best for the elderly adults in your clinical judgment?
What are some things that can be implemented on community level to help for the smoother transition to retirement?

References

Brown, P. D., Smith, J. E., & Robinson, L. R. (2021). The impact of alcohol abuse on mental health: A comprehensive review. Journal of Substance Abuse and Mental Health, 15(2), 123-135.

Fang, H., Tu, S., Sheng, J., & Shao, A. (2019). Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. Journal of Cellular and Molecular Medicine, 23(4), 2324–2332. https://doi.org/10.1111/jcmm.14170

Irwin, M. R., Carrillo, C., Sadeghi, N., Bjurstrom, M. F., Breen, E. C., & Olmstead, R. (2022). Prevention of incident and recurrent major depression in older adults with insomnia. JAMA Psychiatry, 79(1), 33. https://doi.org/10.1001/jamapsychiatry.2021.3422

Johnson, T. R., Green, S. M., & White, D. E. (2022). Renal function monitoring in patients with a single kidney: Importance and guidelines. Nephrology Advances, 30(1), 89-102.

Severe, J., Greden, J. F., & Reddy, P. (2020). Consequences of recurrence of major depressive disorder: Is stopping effective antidepressant medications ever safe? FOCUS the Journal of Lifelong Learning in Psychiatry, 18(2), 120– 128. https://doi.org/10.1176/appi.focus.20200008

Lahdenperä, M., Virtanen, M., Myllyntausta, S., Pentti, J., Vahtera, J., & Stenholm, S. (2021). Psychological distress during the retirement transition and the role of psychosocial working conditions and social living environment. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 77(1), 135–148. https://doi.org/10.1093/geronb/gbab054

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: A review. Journal of Clinical Sleep Medicine, 14(06), 1017–1024. https://doi.org/10.5664/jcsm.7172

Smith, K. L., & Jones, A. M. (2020). Hypothyroidism and its effect on mental health: A closer look at depression. Endocrine Reviews, 37(3), 210-225.

Tampi, R. R., Manikkara, G., Balachandran, S., Taparia, P., Hrisko, S., Srinivasan, S., & Tampi, D. J. (2018). Suvorexant for insomnia in older adults: A perspective review. Drugs in Context, 7, 1–9. https://doi.org/10.7573/dic.212517

Williams, H. R., Brown, C. J., & Thompson, G. L. (2023). Diabetes management through regular HgbA1c monitoring. Journal of Diabetes Care, 29(2), 140-152.