Major Depressive Disorder

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MajorDepressive Disorder

MajorDepressive Disorder

SOAPNote Format

PatientInformation:

InitialsJJ

Age,32

Sex, Female

Race, African American

Insurance Obamacare

S.

CC

Patientstates she is harboring suicidal thoughts. She reports suffering fromdepression. Additionally, she acknowledges beingobsessedwith death.Further, she experiences difficultiesgetting sleep.JJidentifies that she has an irritable mood and has trouble withappetite. Additionally, she reports having feelings of helplessness,worthlessness, and hopelessness.

HPI:

Onset:2 years ago

Location:Generalized

Duration: Steady loss of weight approximately 3-5 pounds per week

Characteristics:Linked with an irritable mood, loss of appetite, feelings ofworthlessness, has suicidal thoughts and is hopeless with her entirelife.

AggravatingFactors:She is lonely, and nobody seems to care much about her whereabouts.She lives alone, and her siblings have stopped checking on her forirritable attitude. They describe her as being unwelcoming henceconcluding that she is best to live alone. Lack of emotional supporthas subjected her into concluding that she is not worth living.Suggests that taking her life would help bring her pain and sufferingto an end.

RelievingFactors:Occasionally a nurse from the mental health facility visits her tocheck on how she is doing. Her grandmother who lives in a differentstate calls on her on a monthly basis. The community she lives infinds time to gather at her place where they share a meal and talkabout different issues in life. She has learned to ingest foods insmall amounts especially when she gets visitors. She gets reassurancefrom the community members on being positive about her life.

Treatment:Previously shewas usingantipsychotic medications including fluoxetine, bupropion, andescitalopram. She abandoned the use of the drugs after determiningthat she was not getting any better.

CurrentMedications:

Currentmedications she is using a mood stabilizer drugs lithium and valproicacid. She takes a dose of 1800 mg of the drug per day. 600mg is takenin the morning and a similar amount taken in the afternoon andnighttime. The choice of the drug emanates from the fact that ithelps the patient attain stability when it comes to management of hermoods (Wiersmaet al., 2011).Valproic acid is equally administered alongside lithium to complementtheir actions. A dosage of 15 mg/kg is taken orally per day. Theintake of the drug should be as prescribed by the physician.Duloxetine has also been used to help in dealing with mood problems.20 mg of the drug is taken twice a day preferably in the morning andnighttime. The condition is appropriate intreating majordepressive disorder (Davidson,2010).The drug should be taken at least two weeks as the patient is beingmonitored.

Allergies: Thepatient was initially on aripiprazole but had to stop takingmedication for the allergic reactions it caused. For example, JJexperienced irritability, dryness of the mouth, heartburn and inextreme cases heartache. The patient initially was using bupropionbut had to stop using the same because of the side effects that itwas associated with. The patient suffered headaches, a skin rash,tremor, migraines, weakness and confusion upon the use of the drug.Theadverse effects associated with the medication negated the need forJJ to stop taking such drugs.

JJisallergic to foods such as nuts, fish, the citrus fruits, peanuts,wheat, and shellfish. Upon intake of the foods, the patient couldsuffer a skin rush and in extreme cases experience convulsions.

Notableenvironmental allergens the patient suffered from included pollenfrom trees, house dust, mold spores, dust mites and pet dander.

PMHx:

JJhas received the nine-valent human papillomavirus (HPV) vaccine thatis a routine vaccination of females aimed at protecting them fromHPV. She has as well received the pneumococcal conjugate vaccineintended to protect the patient from the deadly pneumococcus disease.Further, considering the depressive nature of the patient, it couldbe mandatory to vaccinate the patient with ketamine. The drug hasbeen determined to have a positive effect in depressed patients whomay be harboring suicidal thoughts (Vilhaueret al., 2012).As explained in the CC section, the patient reported that she washaving suicidal thoughts. The use of ketamine is crucial in helpingthe patient deal with the current condition. The drug has since beenused after the FDA approval in the 1970s. The patient has also hadthe Hepatitis B vaccine that is recommended for adults. It protectsagainst the effects of the Hepatitis B virus. Further, the patienthas previously been treated for depression. Administration of theshingles vaccine is efficient in helping the patient. The vaccineprotects against the zoster virus but is useful in helping patientswho have previously been treated for depression (Schmaderet al., 2012).SocialHistory:

JJhad been working at the community library but had to stop after itwas evident from her condition she could not manage the workload. Shewas married but had a divorce. They have a five-year-old daughter wholives with her father. JJ has been abusing alcohol, probably becauseof her condition. She was once addicted to alcohol but overcame thesame courtesy of a community program to help addicts. She is apersistent tobacco smoker and has been smoking for over five years.JJ loves skating. She used to go skating with friends in theneighborhood. She used to love cooking until she lost the appetite toeat and had since decided to leave a private life. Occasionally inthe evening she goes jogging to help get rid of the adverse thoughtsin her mind. JJ has an alarm installed in the house.

FamilyHistory:

Variousenvironmental factors can be attributed to JJ’s major depressiondisorder. Her mother was a victim of domestic violence leading to herdivorce with the husband. Her father was an alcoholic who died due toliver cirrhosis. He was a persistent tobacco user and at some pointwas diagnosed with a respiratory disease. Her elder sister had triedcommitting suicide while her cousin is intuition. Her mother had oncesuffered from depression especially due to the violent nature of thehusband. It could explain the rationale behind JJ’s depressedcharacter. The depressed nature of JJ’s mother could be apredisposing factor for the development of her condition.

Reviewof Systems:

CONSTITUTIONAL:&nbspJJ exhibits signs of weight loss, weakness, and fatigue.

HEENT:&nbspEyes: &nbspNo significant visual loss.

Ears,Nose, Throat: &nbspNormal hearing. Patient exhibits pain whileswallowing foods.

SKIN:&nbspSkin rash evident probably due to allergens caused by drugs sheis using.

CARDIOVASCULAR:&nbspChest pain, palpitations

RESPIRATORY:&nbspShortness of breath

GASTROINTESTINAL:&nbspVomiting and diarrhea. Food avoidance, foul smelling stool,indigestion, nausea

GENITOURINARY:&nbspHas been using contraceptive drugs.

NEUROLOGICAL:&nbspHeadache and common dizziness occurrence, speech problems,psychiatric symptoms

MUSCULOSKELETAL:&nbspdecrease in motion.

HEMATOLOGIC:&nbspNo anemia, bleeding or bruising.

LYMPHATICS:&nbspEnlarged nodes.

PSYCHIATRIC:&nbspDepression and anxiety, difficulty sleeping, mania, difficultyconcentrating.

ENDOCRINOLOGIC:&nbspSweating

ALLERGIES:&nbspPollen, dust, foods such as nuts.

O.

Physicalexam:

CONSTITUTIONAL:&nbspWeight loss and appears fatigued.

HEENT:&nbspEyes: &nbspEyesight normal.

Ears,Nose, Throat: &nbspNormal hearing. Patient exhibits pain whileswallowing foods.

SKIN:&nbspSkin rash evident probably due to allergens caused by drugs sheis using.

CARDIOVASCULAR:&nbspChest pain, palpitations

RESPIRATORY:&nbspShortness of breath

GASTROINTESTINAL:&nbspVomiting and diarrhea. Food avoidance, foul smelling stool,indigestion, nausea

GENITOURINARY:&nbspHas been using contraceptive drugs.

NEUROLOGICAL:&nbspHeadache and common dizziness occurrence, speech problems,psychiatric symptoms

MUSCULOSKELETAL:&nbspdecrease in motion.

HEMATOLOGIC:&nbspNo anemia, bleeding or bruising.

LYMPHATICS:&nbspEnlarged nodes.

PSYCHIATRIC:&nbspDepression and anxiety, difficulty sleeping, mania, difficultyconcentrating.

ENDOCRINOLOGIC:&nbspSweating

ALLERGIES:&nbspPollen, dust, foods such as nuts.

Diagnosticresults:

Depressedmood and loss of interest in conducting the daily activities.

Decreasedself-esteem and low confidence

Thoughtsof self-harm and pessimistic thoughts

Ideasof unworthiness

Declinein appetite

Depressedmood.

A.

DifferentialDiagnoses

Dysthymia(140.01)

Acondition characterized by low mood that is evident for at least twoyears (Hellerstein,2011).

BipolarDisorder (187.09)

Alsoaffects one’s mood but patient experiences alteration indepression.

AnxietyDisorder (190.67)

Thepatient appears fearful and worries about the future.

P.

Accessto support services such as the community groups.

JJcan engage in activities that keep the mind busy with no room toharbor suicidal thoughts.

Encouragepatient to talk about their fears to help overcome the overburdeningissues they have in mind.

Diagnostics:

Clinicalassessments to record current patient status and compare with pastmedical history

Screeningtest

Differentialdiagnoses

DSM-IV-TRand ICD-10 criteria

Rx:

Sertraline-50mg administered orally once a day. Drug effective in treatment ofdepression (AmericanPsychiatric Association, 2010).

Mirtazapine-15mg orally once a day at bedtime. Drug used in treating majordepressive disorder (Whitton,Treadway, &amp Pizzagalli, 2015).

Haloperidol-0.5mg orally 2 to 3 times daily. Drug is effective in dealing withpsychotic symptoms.

Olanzapine-5mg orally once a day (with fluoxetine 20 mg). Drug works best againstpsychosis.

Education:

Drugssuggested helping JJ overcome the major depression disorder followthe stipulated guidelines as pertains to management of mental healthdisorder. However, it is essential to consider that in the case ofadverse reactions from the drugs administered, due measures are inplace to stop the patient from their use.

Referral/Consults:

None

Followup:

Patientexpected to present to the hospital after two weeks for assessment ofher condition. However, in the case of adverse reaction from thedrugs, the patient can report to the hospital as soon as possible.

References

AmericanPsychiatric Association. (2010). Treating :A Quick Reference Guide. Practice,(October), 1–28.

Davidson,J. R. T. (2010). Major depressive disorder treatment guidelines inAmerica and Europe. TheJournal of Clinical Psychiatry,71Suppl E,e04. http://doi.org/10.4088/JCP.9058se1c.04gry

Hellerstein,D. J. (2011). Dysthymic disorder reviewed: Treating chronicdepression in the age of DSM-5. MinervaPsichiatrica.

Schmader,K. E., Oxman, M. N., Levin, M. J., Johnson, G., Zhang, J. H., Betts,R., … Annunziato, P. (2012). Persistence of the efficacy of zostervaccine in the shingles prevention study and the short-termpersistence substudy. ClinicalInfectious Diseases,55(10),1320–1328. http://doi.org/10.1093/cid/cis638

Vilhauer,J. S., Young, S., Kealoha, C., Borrmann, J., Ishak, W. W., Rapaport,M. H., … Mirocha, J. (2012). Treating Major Depression by CreatingPositive Expectations for the Future: A Pilot Study for theEffectiveness of Future-Directed Therapy (FDT) on Symptom Severityand Quality of Life. CNSNeuroscience and Therapeutics,18(2),102–109. http://doi.org/10.1111/j.1755-5949.2011.00235.x

Whitton,A. E., Treadway, M. T., &amp Pizzagalli, D. A. (2015). Rewardprocessing dysfunction in major depression, bipolar disorder andschizophrenia. CurrentOpinion in Psychiatry,28(1),7–12. http://doi.org/10.1097/YCO.0000000000000122

Wiersma,J. E., Titov, N., Van Schaik, D. J. F., Van Oppen, P., Beekman, A. T.F., Cuijpers, P., &amp Andrews, G. A. (2011). Treating chronicsymptoms of depression in the virtual clinic: Findings on chronicityof depression in patients treated with internet-based computerizedcognitive behaviour therapy for depression. Psychotherapyand Psychosomatics.http://doi.org/10.1159/000323167

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