Assessing, Diagnosing, and Treating Adults with Mood Disorders Focused SOAP Note

Assessing, Diagnosing, and Treating Adults with Mood Disorders Focused SOAP Note

Introduction

In young adults, identifying and managing mood symptoms can be a challenge for healthcare providers. Tolliver & Anton (2015) note an increase in the prevalence of comorbid mood disorders in this population. Therefore, conducting a comprehensive family and medical history assessment is crucial for developing an effective treatment plan. Failure to identify mood disorders can lead to higher rates of relapse, recurring mood disorders, and suicidal tendencies. This paper aims to create a focused SOAP note for a young adult patient with a mood disorder, conduct a thorough assessment, establish a differential diagnosis list, and outline a treatment plan.

Chief complaint: The patient seeks a mental health assessment.

History of Present Illness (HPI): Petunia Park, a 24-year-old patient, presents for a mental health assessment. She reports a history of medication use, which she discontinues when she feels it suppresses her creativity. Ms. Park also mentions having hypothyroidism and is currently taking medication for it.

GCU RN-to-BSN Domains; Competencies and NRS-493 Individual Success Plan

Past Psychiatric History

General statement: The patient’s initial encounter with mental health issues occurred during her teenage years when she experienced five days without sleep. She is uncertain about her exact mental condition at that time.

Caregiver: Ms. Park resides with her boyfriend when not at home with her mother, who provides some support.

Hospitalization: She reports being hospitalized four times in the past, with the most recent occurrence in the past spring. She attributes her 2017 hospitalization to a Benadryl overdose. The patient denies any detox or residential rehabilitation.

Medication trial: Ms. Park experimented with several medications, including Zoloft (resulting in heightened feelings), risperidone, and Seroquel (causing significant weight gain), and Klonopin (resulting in slowed down feelings). She also mentions an unspecified medication that stifled her creativity.

Previous psychiatric diagnosis: She has previously been diagnosed with depression, anxiety, and bipolar disorder.

Substance Use History: The patient smokes about a pack of cigarettes a day, began using alcohol at 19, and tried marijuana, which triggered paranoia. She denies using cocaine, stimulants, inhalants, sedative medications, or synthetic substances.

Family psychiatric/substance use history: Her mother has a history of bipolar disorder and suicide attempts, while her father had legal issues related to drugs and mentioned his brother’s possible schizophrenia, although he never sought medical evaluation.

Social History: Raised by her mother and older brother, Ms. Park has one older sibling and is in a relationship with her boyfriend. She is single and childless, attending vo-tech school for cosmetology and pursuing hobbies such as writing and painting. She works part-time at her aunt’s bookstore. She was once taken to the hospital by the police but denies any traumatic or violent experiences.

Medical History: The patient has hyperthyroidism, requiring medication. She reports that her depression hinders her ability to work in the bookstore. During depressive episodes, she experiences extreme fatigue, lacks motivation, remains in bed, and feels unworthy after extended periods of intense work.

Current Medication: Medication for hypothyroidism.

Allergies: No known allergies.

Reproductive History: Ms. Park identifies as heterosexual, experiences regular menses, has never been pregnant or lactated, and takes birth control pills for polycystic ovaries. She admits to having multiple sexual partners.

Review of Systems (ROS)

GENERAL: The patient is alert and oriented but appears agitated when asked certain questions. She denies fever, chills, weakness, and fatigue. Her appetite is good, and she typically sleeps 5-6 hours a night on average.

Assessing, Diagnosing, and Treating Adults with Mood Disorders Focused SOAP Note

Introduction

In young adults, identifying and managing mood symptoms can be a challenge for healthcare providers. Tolliver & Anto

: No headaches or dizziness reported. No issues with vision, hearing, or sinus discomfort. No neck stiffness, pain, or injury. No recent dental examinations.

SKIN: No rash, itching, or wounds.

RESPIRATORY: No chest pain, shortness of breath, coughing, hemoptysis, congestion, or edema.

CARDIOVASCULAR: No palpitations, wheezing, murmurs, or chest pain.

GASTROINTESTINAL: No abdominal pain, nausea, diarrhea, or loss of appetite.

GENITOURINARY: No painful urination, urgency, odor, or discoloration.

NEUROLOGICAL: The patient reports episodes of abnormal sleep patterns, reduced energy, and feelings of worthlessness.

MUSCULOSKELETAL: No muscle cramps, weakness, painful joints, or stiffness.

HEMATOLOGY: No signs of anemia or bleeding.

LYMPHATIC: No enlarged lymph nodes or history of splenectomy.

ENDOCRINE: No issues with sweating or temperature intolerance.

Objective

Physical exam: Temperature 98.2°F, Pulse 90, Respiration 18, Blood Pressure 138/88.

The patient is alert and oriented but appears agitated when asked certain questions. She is well-groomed and communicates effectively.

Diagnostic Results: Negative results for urine drug and alcohol screenings. CBC and CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (high).

Assessment

Mental Health Examination

The patient, a 24-year-old female, exhibits anxiety and occasional agitation. She remains alert and oriented to time and place, maintains appropriate grooming, and sustains eye contact during the interview. Her speech is clear but at times pressured, yet she comprehends her verbalizations. She can express thoughts and feelings without hallucinations, delusions, or paranoia. The patient reports experiencing depressive episodes following periods of high energy and intense work. During these episodes, she lacks energy, motivation, and the desire to leave her bed, often feeling unworthy.

Differential Diagnosis

Manic Depression: Calabrese et al. (2017) describe the diagnostic criteria for bipolar disorder, including persistent elevated or irritable mood, increased goal-directed energy lasting at least one week, and the presence of increased energy and at least four of the following: decreased need for sleep, inflated self-esteem, increased talkativeness, and excessive engagement in pleasurable activities. The patient experiences depressive episodes following periods of high energy and intense work, lasting about a week.

Major Depressive Disorder: According to the DSM-5 criteria, major depressive disorder (MDD) requires the presence of either depressed mood or loss of interest for at least two weeks, along with a minimum of five other symptoms, including weight loss, insomnia, suicidal thoughts, difficulty concentrating, fatigue, and psychomotor retardation (Tolentino & Schmidt, 2018). The patient reports a depressed mood and loss of interest, which last for a week.

Premenstrual Dysphoric Disorder: Reid (2017) outlines diagnostic criteria for premenstrual dysphoric disorder, involving marked affective lability and irritability, along with at least five of the following: depressed mood, anxiety, decreased interest in activities, concentration difficulties, changes in appetite, and insomnia.

The most accurate diagnosis for the patient appears to be manic depression, as she experiences depressive episodes following periods of high energy and intense work, with these episodes typically lasting a week.

Treatment Plan

The treatment plan considers various patient factors, including current medications, previous medication reactions, and existing comorbidities. These factors will guide the implementation of the treatment plan, which should be continuously monitored and adjusted as necessary. Given the patient’s hyperthyroidism, initiating Valproate 250mg twice daily instead of lithium is recommended, as lithium could exacerbate her thyroid condition. Shah et al. (2017) have found Valproate to be effective in treating acute mania, with fewer severe side effects. Educating the patient on potential signs of hepatic and hematological dysfunction is crucial. Monitoring serum valproate levels and assessing symptom improvement will determine the need for dosage adjustments or discontinuation (Shah et al., 2017). Additionally, encouraging the patient to establish a consistent and healthy daily routine to stabilize moods is essential.

Reflection

This case study highlights the importance of conducting a comprehensive evaluation to accurately diagnose mood disorders. Given the overlapping symptoms of different mood disorders, a systematic diagnostic approach is crucial to rule out potential differential diagnoses. Treatment decisions should be based on the specific diagnosis while taking into account the patient’s individual factors. Involving the patient’s caregiver could provide valuable insights. Ethical considerations, such as informed consent and confidentiality, must be upheld. Social determinants of health, such as ethnicity, gender, sexual orientation, income, and education, can increase the risk of mood disorders and should be considered when recommending health promotion strategies.

References

Calabrese, J. R., Gao, K., & Sachs, G. (2017). Diagnosing mania in the age of DSM-5. American Journal of Psychiatry, 174(1), 8–10. https://doi.org/10.1176/appi.ajp.2016.16091084

Reid RL. Premenstrual Dysphoric Disorder (Formerly Premenstrual Syndrome) [Updated 2017 Jan 23]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Table 1, Diagnostic Criteria for Premenstrual Dysphoric Disorder (PMDD) Available from: https://www.ncbi.nlm.nih.gov/books/NBK279045/table/premenstrual-syndrom.table1diag/

Shah, N., Grover, S., & Rao, G. P. (2017). Clinical practice guidelines for management of bipolar disorder. Indian Journal of Psychiatry, 59(5), 51. https://doi.org/10.4103/0019-5545.196974

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00450

Tolliver, B. K., & Anton, R. F. (2015). Assessment and treatment of mood disorders in the context of substance abuse. Dialogues in Clinical Neuroscience, 17(2), 181–190. https://doi.org/10.31887/dcns.2015.17.2/btolliver