Focused soap note and patient case presentation, 21

7:2 O N (21years )

Learning Objectives:

1. Analyze the difference between Major depressive disorder (Recurrent) without psychotic features and Bipolar 1 disorder.

2. Understand the effect of substance use disorder on a patient with MDD, HIV, and IDDM.

3. Identify how patients with MDD have an Increased risk of premature death due to the increased risk of suicide and medical comorbidities, including HIV endocrine causes.

Subjective:

CC (chief complaint): I feel depressed continuously; I wanted to kill myself; I do not want to be on earth anymore”.

HPI: DK is a 21 yr. Old African American male, single, domiciled at the shelter, unemployed and with no support, with a past psychiatric history of Bipolar disorder, suicidal attempt, polysubstance abuse, and past medical history of DM and HIV with a history of non-compliance with ART. DK came into the clinic from his residence (shelter). He came for his initial visit one week after being discharged from the hospital, looking for a psychiatrist for medication management. He does not have a PCP and has a history of non-compliance with medication. The patient stated that he was depressed after his diagnosis of HIV, had attempted suicide, and was subsequently diagnosed with major depressive disorder. He had a history of poorly managed diabetics, constantly feeling hopeless and losing interest in things he used to enjoy in the past, as well as living in a shelter. The patient attempted suicide by injecting himself with a month’s supply of insulin, which landed him in the ICU for 7 days. During the interview, the patient stated, “I do not know what is wrong with my f…king brain; I was discharged from the hospital, I did not take my medications and went on doing drugs, now I feel so stupid and want to kill myself,”. He also stated, ” Somebody in the shelter saw me snorting crack cocaine and went to talk; everyone is looking at me like a FOG+T GAY smoking crack. I wanted to stab him, but I went and cut myself instead. He has a history of noncompliance because of the complexity of his situation. According to him, his family disowned him when he identified himself as wanting to be gay at age 15. The patient has a history of illicit drug use, acknowledged that he was still using drugs, and was non-compliant due to losing interest in everything around him.

Past Psychiatric History: The patient has a psychiatric history of MDD (major depressive disorder), recurrent, without psychotic features, with a long history of going in and out of various psych hospitals. He reported more than 15 hospitalizations over time, and three hospitalizations have occurred in 2023. The patient’s last admission was on 9/18/23 for 7 days. The patient was referred to an outpatient psychiatric clinic multiple times but did not follow up and has been non-compliant with medications.

Medical History: Type 2 Diabetes, HIV.

Current Medications: He was not compliant with any medication; he lost all his medication at the shelter and cannot recall the names of the medications.

Allergies: NKA

Reproductive HX: Homosexual but not currently sexually active.

Legal History: Denied any form of legal problem.

Past Surgeries: No past surgery

Abuse and Trauma History: The patient acknowledged sexual and physical abuse while he was still with his family as a teenager.

Social History: The presented patient was born in Connecticut. He had a normal upbringing till he was 12 and started realizing that there was something different about him; he is the 5th child of 7 and had an abnormal upbringing due to his sexual orientation. In addition, the patient acknowledged academic difficulties in school. Throughout school, he felt bullied and had a few close friends. The patient reported that his parents would discipline him when they needed to, and when he felt unloved, he left home, and that was when his problem started. The patient acknowledged being physically and sexually abused. The patient was unable to complete his high school education. He had tried to get a job but is currently unemployed and receiving SSI. He would love to go back to school or to get a job.

SUBSTANCE USE: The patient has a history of substance abuse. He is a chronic cigarette smoker and cocaine and marijuana abuser. The patient is also a heavy drinker; he drinks to see if alcohol can help him forget his troubles and worries. He is also a lover of caffeine and consumes a large quantity each day.

Family Psych/Chemical History: His mother struggled with alcohol abuse while his father was in jail, and his father was never in the picture when he was at home.

ROS:

(  GENERAL: he is not in acute distress.

(  HEENT: Normocephalic and atraumatic, No congestion with mucous membrane dry. Eyes with no scleral icterus

(  SKIN: Dry with no redness, itchiness or scars.

(  CARDIOVASCULAR: No chest pain, dizziness, no complaints of any cardiovascular issues.

(  RESPIRATORY: No shortness of breath or any history of asthma.

(  GASTROINTESTINAL: No complaints or concerns, no diarrhea or constipation.

(  GENITOURINARY: No complaints or concerns

(  NEUROLOGICAL: Negative for headache or dizziness; Negative for seizures or trauma.

(  MUSCULOSKELETAL: No musculoskeletal problem.

(  HEMATOLOGIC: No complaints or concerns. No bruising or bleeding.

(  LYMPHATICS: No complaints or concerns.

(  ENDOCRINOLOGIC: IDDM, uncontrolled with palmar sweating. No headache.

Mental Status Exam: Appearance: Appeared stated age; he is alert and oriented to person, place, and time. Well-groomed and was cooperative during the interview. My patient endorsed a sad mood, low energy, poor sleep, and poor appetite. He endorsed feelings of hopelessness, helplessness, and worthlessness. He denied anhedonia. He endorsed suicidal ideation and intention to kill himself by opening his veins. He denied visual or auditory hallucinations. He denied thought insertion, thought withdrawal, and broadcasting. He endorsed some reference ideas, believing his thoughts are sometimes displayed on the TV screen. He denied paranoid delusions. He did not exhibit negative symptoms of psychosis. Attitude: Cooperative, Psychomotor Activity: Calm, Speech: Normal rate and volume Mood: Euthymic, Affect: Full, Reactive, Stable. Thought Process: Goal-directed, Logical, Organized, General Knowledge: Adequate. Insight and judgment are fair.

SUICIDE RISK ASSESSMENT: low risk using the Columbia Suicide Severity Rating Scale

The Patient Health Questionnaire – 9 (PHQ-9): 22

Diagnosis and Differentials:

Major depressive disorder (MDD): Major depressive disorder is the primary diagnosis for this patient; according to the World Health Organization (WHO), Major depressive disorder (MDD) is known as the third leading cause of illness burden, and it is predicted to rank number one by the year 2030 (Mughal S et al., 2022). It is also reported that two-thirds of patients with depression think of suicide, while up to 15 percent commit suicide. MDD is a chronic, recurrent illness. It is diagnosed when a person is consistently in a low or depressed mood, anhedonia or loss of interest in pleasurable activities, guilt or worthlessness, a lack of energy, poor concentration, decreased appetite, difficulty concentrating or agitation, sleep problems, or suicidal thoughts (American Psychiatric Association, 2013). Patients with MDD, as per DSM-5, have problems with interpersonal relationships, getting and keeping a job, and maintaining self-care for more than six months ( APA, 2022). My presented patient showed more than 5 signs and symptoms of depression, such as a lack of energy and worthlessness, restlessness, guilt, anhedonia, sleeping problems, and difficulty concentrating. Other contributing factors supported this diagnosis, including his medical conditions, a PHQ-9 score of 22, being homeless, and even his sexual orientation, and as such, Major Depressive Disorder is his primary diagnosis.

Bipolar 1 disorder: According to the DSM-5, while diagnosing a Bipolar Disorder in a patient, there has to be a period of manic or hypomanic with a more depressive mood. This patient’s presenting symptom is noted to have started in his early teenage years, with everyday disturbance in mood: mood swings, irritability, and a feeling of guilt. The patient has experienced instability, leading to hospitalization more than 15 times. He had experienced a period of unusually intense emotion, changes in sleep patterns and activity levels, and other uncharacteristic behaviors (O’Donnell et al., 2018). However, this patient does not meet the criteria to be diagnosed with bipolar as his primary diagnosis because it has not gotten to the point of hospitalization, as per DSM 5 guidelines.

Substance use disorder: The patient is also struggling with substance use disorder. According to DSM-5 definition, it identifies substance use disorder as the primary behavior of those who misuse substances. These criteria specify a type of addiction that includes behavioral, physiological, and cognitive symptoms. This patient’s substance use is not only problematic. It has caused a lot of distress and impairment. It affected him socially, and he continued to use it despite its danger to his life as a patient with uncontrolled diabetes who should take medication daily for various reasons (APA, 2022).

Case Formulation and Treatment Plan:

Diagnostic results: Patient CBC, CMP, BUN, AST, ALT, Complete blood cell (CBC) count

Thyroid-stimulating hormone (TSH), Vitamin B-12, HIV Viral load– Pending

Legal and Ethical Considerations:

The legal and ethical consideration to adhere to while treating DK was to ensure I was unbiased and keep the practices within my nursing scope. Patients will be treated with respect and unjudgemental with empathy. All the needed help and resources will be provided to assist him with being compliant as much as possible (Boland & Verduin, 2021).

Pharmacology and psychotherapy: After examining the patient and his hospitalization history. The patient was started on Lexapro 5mg for depression, Abilify 5mg PO daily for mood stabilization, gradually titrated up10mg Abilify PO daily, Depakote 500mg PO bid for mood stabilization, and Trazodone 50mg PO for insomnia as needed. The patient was also offered Naltrexone 25mg daily and nicotine gum for his smoking habit, which he refused. The patient will continue on his diabetic and HIV medications as prescribed, with his blood sugar continuously monitored. Not only does he have diabetes, but using Abilify can also increase his blood sugar (Stahl, 2020). DK will be educated and encouraged to switch to long-acting Abilify Maintena 300mg due to his history of non-compliance with his oral medication.

Psychotherapy: Medications in combination with psychotherapy (cognitive-behavioral therapy, interpersonal therapy) 30-minute sessions every three weeks for 6 months.

DK was provided care coordination services to help connect him to community-based resources, such as support groups, mental health centers, and substance use treatment programs.

Education: The patient was educated on the meaning of depression, the signs and symptoms to look out for, and, more importantly, the need not to be stigmatized due to his diagnosis. Patient was encouraged to avoid drinking alcohol or any other illicit drugs. The treatment goal was discussed with the patient on how to prevent and improve the patient’s psychiatric and medical conditions. Patient teaching was provided to understand the purposes of the various medications being prescribed; the patient was made aware of what symptoms to look for regarding exacerbation of the condition, and knowledge of what symptoms or states of mind constitute an emergency was discussed in detail with the patient. The patient was educated on needing to comply with his medication with the rationales reinformed. He was given a notebook to write any questions to ask during his next visit.

Follow-up: Due to the patient’s history of non-compliance, the patient was scheduled for a follow-up appointment Biweekly for medication management and his initial psychotherapy and was always instructed to call a crisis number or a suicide hotline with any questions and concerns.

• Referral to PCP to manage his HIV and his poorly controlled DM.

Reflection:

My presented patient has a long history of undertreated mental health that resulted from his noncompliant and complex case of other medical diagnoses. I have learned a lot about major depressive disorder and how, according to research, its contributing factors include genetics, environmental, psychological, and even biological issues. The patient experienced much stress in his early life that could have altered his neuroendocrine and behavioral responses, resulting in severe depression
. More so, the patient has a comorbid disorder of substance use disorder, HIV, and uncontrollable diabetes that increased his risk factors of suicidal attempts (Bains N. et al., 2022). My preceptor and I understood that the only way out for this patient would be to help him get a PCP to manage his medical issues. We set him up with a social worker to help him secure better accommodation in a group home setting that can manage his health issues. Finally, collecting collateral information from a patient’s family and friends will also be essential to the psychiatric evaluation, diagnosis, and treatment of his Major depressive disorder.

Discussion Questions

How can my patient be encouraged to comply more with his treatment plan to avoid frequent hospitalization?

What is your take on PO versus long-acting IM medication for my patient? Which one do you think will help with DK’s complaint?

What other treatment plan can you suggest for my patient?

Have you had any such encounters with your patient, and how was it managed?

References

Association, A. P. (2022). Diagnostic and statistical manual of mental disorders, fifth edition,

text revision (DSM-5-TR(TM)) (5R ed.). American Psychiatric Association Publishing.

Bains N, Abdijadid S. Major Depressive Disorder. ( 2022).

https://www.ncbi.nlm.nih.gov/books/NBK559078/

ChandSP, Arif H, Kutlenios RM. Depression (Nursing) [Updated 2023 Jul 17]. In: StatPearls

[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK568733/

Jain A, Mitra P. Bipolar Disorder. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure

Island (FL): StatPearls Publishing; 2023 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK558998/

Mughal S, Azhar Y, Siddiqui W, et al. Postpartum Depression (Nursing).

In: StatPearls Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available

from: https://www.ncbi.nlm.nih.gov/books/NBK568

O’Donnell, L. A., Ellis, A. J., Van de Loo, M. M., Stange, J. P., Axelson, D. A., Kowatch, R. A.,

Schneck, C. D., & Miklowitz, D. J. (2018). Mood instability as a predictor of clinical and

Functional outcomes in adolescents with bipolar I and bipolar II disorder. Journal of

Affective Disorders, 236, 199–206. https://doi.org/10.1016/j.jad.2018.04.021

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of

psychiatry (11th ed.). Wolters Kluwer.

Stahl, S. M., Grady, M. M., Muntner, N., Wong, D. A., & Shapiro, D. (2020). Stahl’s Essential

Psychopharmacology: Prescriber’s Guide: Children and Adolescents. Cambridge

University Press.