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Please choose a self-reflection topic from the attached form and write a clinical self-reflection based on an the SOAP Note below:
1. Identification:
M.K. is a 17-year-old male of mixed race, comprising Caucasian and Native American heritage. He is single but in a committed relationship and is soon to become a father. The patient reliably narrates his medical history without needing an interpreter.
2. CC (Current Conditions/chief complaint)
I struggle with focusing, concentrating, and sleeping. I feel depressed and paranoid, and I constantly feel like I am being followed.
3. HPI (History of Present Illness)
M.K. has presented to the clinic with a history of Major Depressive Disorder, Anxiety Disorder, and ADHD. The patient reports experiencing persistent symptoms, including poor focus and concentration, racing thoughts, and an inability to maintain a balanced sleep pattern. He also describes feelings of hopelessness and paranoia, along with flashbacks from past trauma, and he frequently feels like he is being followed, confirming a history of hallucinations.
While the patient denies any active suicidal thoughts or intentions to self-harm or harm others, he admits to a history of substance abuse and previous suicide attempts, with his last attempt occurring in September 2023 due to a fentanyl overdose. Additionally, he struggles with an addiction to smoking and vaping and is currently on probation for substance abuse at school.
4. Medications
No current medications were reported. The patient has a history of polysubstance use, has undergone residential treatment for chemical dependency, and has a detox history.
5. Allergies
Seasonal allergies.
6. Past Psychiatric History
The patient has been diagnosed with Major Depressive Disorder, Generalized Anxiety Disorder, and ADHD. He has two instances of psychiatric hospitalization and a history of 10-15 suicide attempts, including a fentanyl overdose. Currently, the patient is staying in a shelter after completing a polysubstance detox.
7. PMH and PSH
Acid reflux, recurrent toothaches, chronic cough with wheezing and chest pain, three to four concussions resulting in a brief loss of consciousness, and two instances of right-hand fractures. The patient has no surgical history.
8. Social History
Substance Use History: The patient smokes four cigarettes daily and vapes regularly, using a product with 5% nicotine. He rarely consumes alcohol but engages in occasional drinking during parties. The patient’s use of illicit drugs began at the age of 14, including fentanyl and other substances, with polysubstance use peaking before Thanksgiving. This pattern of use ultimately led to his admission for detoxification.
Employment: He is unemployed and is a senior in high school.
Relationship Status: The patient is a single, soon-to-be father in a committed relationship.
Sexual History: The patient reports a stable relationship with the child’s mother, with no other recent partners noted.
Violence Screen: The patient reports feeling safe in the shelter despite having a history of past traumas, which include experiences of physical abuse, being stabbed, and being jumped multiple times. The patient does not have access to firearms.
Regarding perinatal history, the patient reports no exposure to drugs or alcohol during pregnancy. The delivery was a full-term vaginal birth, and there is no feeding history available.
Childhood: Despite the unstable environment, the patient has achieved all milestones and has not encountered significant education-related challenges.
Educational history: The patient is currently at the senior high school level despite a history of behavioral issues and substance-related suspensions during his academic journey.
Trauma/abuse history: His father’s physical abuse, especially when drunk, triggered the patient’s emotional trauma as his 15-year-old cousin sexually abused him, triggering the CPS at the age of six years. The patient has also experienced other traumatic events, including a stabbing last year and three to four concussions accompanied by loss of consciousness.
Legal history: Although the patient denies legal involvement, he is currently on probation for substance abuse and smoking at school. Additionally, he has minor alcohol consumption arrests and a history of polysubstance abuse.
Adaptive history: Despite significant childhood challenges, the patient has shown resilience in various areas, including overcoming physical abuse, while also pursuing education up to the high school level. As for religious and spiritual beliefs, the patient has not indicated any spiritual affiliation.
9. Family History
Maternal History: The patient’s mother has a history of mood disorders, anxiety disorders, and post-traumatic stress disorder (PTSD).
Paternal History: The patient’s father is dealing with mood disorders, anxiety disorders, bipolar disorder, PTSD, and alcoholism.
Siblings: The medical history indicates that the patient’s paternal sister has an anxiety disorder, while the maternal sister has severe attention deficit hyperactivity disorder (ADHD).
10. Review of Systems
General: The patient reports experiencing fatigue, fluctuations in weight, and disrupted sleep patterns.
Skin: The patient has smooth skin without rashes, lesions, or discolorations.
HEENT: The patient reports a history of 3-4 concussions, each accompanied by a loss of consciousness. Additionally, he is experiencing a persistent toothache.
In terms of cardiovascular and respiratory health, the patient mentions possibly dealing with high blood pressure; however, there is no confirmed diagnosis. He does present with a persistent cough that produces phlegm and a wheezing sound, along with chest pain.
Gastrointestinal: According to the patient, he has an acid reflux history.
GI/GU: The patient does not present any GU-associated symptoms.
Neurology: A persistent concussion history associated with loss of consciousness but without any seizure history.
Psychiatric ROS.
Sleep: The patient reports experiencing sleep disturbances characterized by nightmares.
Interest: The patient has not indicated a continuous loss of interest in daily activities.
Guilt: The patient describes an emotionally troubled life, which contributes to feelings of hopelessness.
Energy: The patient does not report experiencing increased fatigue.
Concentration: The patient indicates having poor focus and concentration, along with increased distractions.
Appetite: The patient does not report a declining appetite despite worsening health.
Psychomotor: The patient denies any symptoms related to psychomotor agitation or retardation.
Suicidality: Although the patient has attempted suicide approximately 15 times, he reports no current suicidal thoughts.
Mania (DIGFAST)
Distractibility: The patient’s current condition and symptoms are consistent with ADHD.
Impulsivity: The patient’s condition and presenting symptoms indicate impulsive behaviors.
Grandiosity: There are no visible signs of grandiosity based on the patient’s illustrations.
Flight of Ideas: The patient reports racing thoughts, which suggest triggers related to paranoia.
Activities: The patient’s composed posture reflects a sense of calmness but reacts when provoked.
Sleep: The presence of nightmares indicates disordered sleep patterns in the patient.
Talkativeness: The patient’s fluent speech is not accompanied by pressured instances, making it understandable.
Anxiety Disorders.
Generalized Anxiety Disorder (GAD): The patient’s racing thoughts contribute to his worrying behavior, leading to this condition (Green & Graham, 2021).
Post-Traumatic Stress Disorder (PTSD): Childhood traumas contribute to the patient’s PTSD, which is exacerbated by his state of hypervigilance (Green & Graham, 2021).
Obsessive-Compulsive Disorder (OCD): The patient confirms this condition by describing his “obsessive” behaviors (Green & Graham, 2021).
Agoraphobia/Panic Disorder: The patient reports that they do not experience any panic attacks when speaking in public.
Psychosis: The patient experiences hallucinations, characterized by frequent thoughts of someone following them, along with feelings of paranoia, which are indicative of psychosis.
Eating Disorders (Somatoform): The patient shows no signs of anorexia.
Personality Disorders: Traumatic childhood experiences have led to emotional dysregulation.
Cognitive Disorders: The patient denies experiencing cognitive decline.
Somatization: The patient is experiencing persistent chest pain and a constant cough.
Objective
Descriiption: This section includes information from your objective observations, which are things you can measure, see, hear, feel, or smell while performing your psychiatric interview.
1. Vital Signs
Temp: 98.6 0F, BP: 136/ 88, HR: 90, SpO2: 97%, RR: 18, BMI: 21.5.
2. Mental Status Exam
Appearance: The patient appears disheveled but cooperative. He exhibits a guarded personality, although he responds when prompted.
Speech: His speech is slow and monotone, yet coherent.
Mood/Affect: The patient reports experiencing feelings of depression and anxiety.
Thought process: The patient seems organized but exhibits paranoid behavior.
Hallucinations: He reports experiencing visual hallucinations and often feels as though he is being followed.
Cognition: The patient is alert and oriented to person, place, time, and situation but exhibits impaired attention and memory.
Insight/Judgment: The patient has limited insight and impaired judgment.
Testing
Complete Blood Count (CBC): This test will help identify anemia and infections that may contribute to fatigue and low energy.
Comprehensive Metabolic Panel (CMP): This test assesses liver and kidney functions, electrolytes, and overall metabolic health, considering the patient’s history of substance abuse (Sabeen et al., 2023).
Urine Drug Screen (UDS): This test confirms detoxification status and identifies potential drug abuse (Sabeen et al., 2023).
Chest X-ray (CXR): This test evaluates issues related to chronic cough, wheezing, and chest pain (Sabeen et al., 2023).
Screening and Assessment Tools
Beck Depression Inventory (BDI): This tool helps quantify the severity of depressive symptoms (Waheed et al., 2024).
Patient Health Questionnaire-9 (PHQ-9): This test helps evaluate and monitor depressive symptoms over time (Waheed et al., 2024).
Mood Disorder Questionnaire (MDQ): This tool is designed for screening bipolar spectrum disorders, particularly mania and hypomania (Waheed et al., 2024).
CAGE Questionnaire: This tool assists in assessing alcohol dependence (Feulner et al., 2024).
Alcohol Use Disorders Identification Test (AUDIT): This assessment tool helps evaluate alcohol use and identify risky drinking patterns (Feulner et al., 2024).
Assessment
Descriiption: This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem.
1. Priority Diagnosis
Major Depressive Disorder, Recurrent, Severe without Psychotic Features (F33.2): The patient experiences a persistent depressed mood, feelings of hopelessness, poor concentration, and sleep disturbances, along with repeated suicidal attempts (Urban-Kowalczyk et al., 2022).
2. Differential Diagnosis
Schizophrenia (F20.9): M.K. reports experiencing hallucinations and paranoia, alongside a history of trauma and substance abuse. Additionally, he exhibits mood disturbances and psychotic features, which complicate the diagnosis (Anczewska et al., 2022). The PCL-5 (Post-Traumatic Stress Disorder Checklist) would assist in differentiating the diagnosis by evaluating trauma-associated symptoms as well as confirming a familial history of psychotic disorders (Orovou et al., 2021).
Substance-Induced Psychotic Disorder (F19.959): M.K. has a documented history of polysubstance abuse, which may have exacerbated his substance-induced psychosis. He reports paranoia and hallucinations likely arising from opioid abuse, including fentanyl overdose, as well as nicotine use (Hua et al., 2024). Urine drug screenings (UDs) would help test for substance abuse, while the CAGE questionnaire would aid in assessing alcohol and substance dependence (Sabeen et al., 2023).
PTSD (F43.10): The patient has a history of childhood trauma, including physical and sexual abuse, with exposure to violence likely contributing to his PTSD. He reports experiencing flashbacks, nightmares, and hypervigilance, which indicate trauma-associated symptoms (Schnider et al., 2022). The PCL-5 tool would help assess PTSD and differentiate trauma-related symptoms from psychotic features. Additionally, the PHQ-9 would help evaluate symptoms of depression (Waheed et al., 2024).
3. Suicide and risk assessment
Suicidal Ideation: M.K. has a history of suicidal behavior, with 10-15 attempts, including a fentanyl overdose. This is compounded by a background of depression, trauma, and substance abuse, all of which likely contribute to his suicidal tendencies.
**CASE Approach**
– **C (Context):** M.K. has a historical record of trauma and abuse coupled with mental health challenges. He is currently residing in a shelter and facing the responsibilities of impending fatherhood.
– **A (Affect):** The patient reports feelings of hopelessness and paranoia, which suggest a low mood that may contribute to his risk of suicidality.
– **S (Situation):** M.K.’s history of suicide attempts, current probation status, and ongoing substance abuse complicate his emotional state.
– **E (Evaluation):** M.K. has a documented history of suicidal attempts as of September 2023, indicating a persistent risk of suicide despite his denial of any current thoughts of self-harm.
Imminent Plan: Although M.K. denies any current suicidal thoughts, the recent overdose and frequent suicide attempts indicate a significant risk; therefore, ongoing monitoring and reassessment are essential.
M.K. has no homicidal ideation; however, his history of aggression and involvement in violent incidents indicate a need for assessing impulsivity and anger, as well as considering the potential for behavioral escalation in stressful situations.
The patient has not indicated any intent or plan to harm others; however, any expression of such intent would require reporting to authorities under the Tarasoff duty to warn.
Plan
Descriiption: In this section, you should include What is the evidence-based plan for treating the diagnosis you picked as the priority diagnosis, including pharm, non-pharm, pt. Education, referrals, and f/u? Each part of the plan needs to be supported by evidence.
Plan with Evidence-Based Support:
1. Diagnostic Measures, Testing, Screening, and Rating Tools**
**Beck Depression Inventory (BDI)**: Used to assess M.K.’s depression symptoms.
**Patient Health Questionnaire-9 (PHQ-9)**: This tool helps evaluate the patient’s depression status and track changes over time, including issues related to sleep disturbances and concentration (Waheed et al., 2024).
**Mood Disorder Questionnaire (MDQ)**: Utilized to assess the likelihood of bipolar disorder and racing thoughts, aiding in the differentiation of diagnoses (Waheed et al., 2024).
**CAGE Questionnaire**: This tool assesses the patient’s history of alcohol and substance use disorders (Feulner et al., 2024).
**PTSD Checklist for DSM-5 (PCL-5)**: Used to evaluate PTSD and symptoms associated with trauma (Orovou et al., 2021).
**Urine Drug Screen (UDS)**: Employed to monitor substance-induced psychosis and related issues (Sabeen et al., 2023).
2. Therapeutics
**Pharmacologic Treatment:**
**Selective Serotonin Reuptake Inhibitor (SSRI):**
Zoloft (50 mg) should be taken orally once daily for the management of Major Depressive Disorder (MDD) alongside anxiety. During bi-monthly follow-up appointments, the healthcare provider can assess the patient for potential side effects, such as nausea and insomnia, and adjust the dosage if necessary (Edinoff et al., 2021).
**Antipsychotic:**
The healthcare provider may prescribe aripiprazole (10 mg) to be taken orally once daily to improve depression management. Dosage adjustments will be made based on the patient’s assessment, with a maximum dosage of 30 mg (McIntyre et al., 2024).
**Severe Sleep Disturbances:**
For patients experiencing increased depressive symptoms and insomnia, along with psychosis, the attending healthcare professional may prescribe quetiapine (25 mg) to be taken at bedtime (McIntyre et al., 2024).
**Naltrexone:**
The healthcare provider may also prescribe naltrexone (50 mg) in oral form for the management of alcohol and opioid dependence (McIntyre et al., 2024).
Non-Pharmacologic: Sleep hygiene involves prescribing and counseling patients on maintaining regular sleep patterns. Reducing caffeine intake and avoiding screens approximately one hour before bedtime can enhance sleep quality.
3. Psychotherapy:
Cognitive Behavioral Therapy (CBT) can improve the management of negative thoughts as patients develop problem-solving skills (Peters et al., 2021).
Trauma-Focused CBT: This therapy should begin once acute symptoms have decreased to address the patient’s traumatic experiences (Peters et al., 2021).
Psychotherapy or Interpersonal Therapy: These therapeutic approaches help enhance a patient’s emotional regulation (Peters et al., 2021).
4. Patient Education/ Anticipatory Guidance:
Patient education should cover the benefits of medication adherence and potential side effects. It is important to highlight the risks associated with aripiprazole and stress the importance of regular follow-up appointments. Healthcare professionals should also caution patients about the dangers of combining medications with alcohol and substance abuse. Additionally, providers should explain the advantages of participating in recovery programs, such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) (Waite-Labott, 2022).
5. Referrals.
Referring to a psychiatrist will improve ongoing medication management.
Referring to a substance use treatment program will enhance the management of polysubstance abuse.
Referring to a trauma specialist will strengthen trauma-focused CBT and EMDR.
6. Follow-up.
The patient’s weekly therapy sessions for 4 to 6 weeks will improve the assessment of their progress. Bi-monthly follow-ups will help evaluate medication effectiveness, alongside monitoring for potential side effects and necessary adjustments.
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