Focused SOAP Note And Patient Case Presentation

Patient is an alert and oriented 33-year-old African American female seen via telehealth with consent with chief complaint of not feeling good about herself and feeling hopeless, helpless and worthless. She reports she is stressed because she has four children and no financial or emotional support from any of the four fathers. She reports a prior suicide attempt in 2012 via an overdose of muscle relaxants and oxycontin. At discharge from hospital, she was started on Wellbutrin and clonidine. She reports the Wellbutrin worked but the clonidine made her fuzzy. She has a history of asthma. She has NKDA. She has a history of asthma and uses and uses an Albuterol inhaler PRN. Hospitalized in 2012 for overdose and childbirth. She has four children ages 14, 11, 5 and 1. She reports there is no family history of mental illness. Mom was primary caregiver. Dad seldomly around and not really significant in her life. She is not married. She is using IUD for contraception. She has no outstanding legal issues. She graduated from high school. She is currently working at Amazon. She reports she is only sleeping 5 to 6 of sleep and her “appetite is terrible.” She smokes marijuana daily, smokes cigarettes, and consumes alcohol. She reports increased use of alcohol this week to manage her stress.

Diagnosis: MDD. PHQ-9 20/27.

Patient is an alert and oriented 33-year-old African American female with complaint of worthlessness, hopelessness, and helplessness who has a prior history of overdose suicide attempt with pills. She was treated with Wellbutrin and clonidine in the past. She had a good response to Wellbutrin. Clonidine left her fuzzy. I will restart Wellbutrin 150mg to address her depression and Vistaril 25 mg by mouth prn, every 8 hours for sleep and anxiety. I instructed her in the use of Wellbutrin, it will help her to decrease her tobacco intake. I instructed her that she cannot smoke marijuana or consume marijuana. It will affect absorption of the medications. Patient verbalized understanding. I instructed patient in sleep hygiene and to go to bed at a routine time and get up at same time. I discussed eating a healthy diet and exercise to promote an overall good healthy feeling and increase natural serotonin. Patient verbalized understanding. I instructed her to do something of interest, that brings her pleasure and to avoid eating after 7pm. Patient verbalized understanding. Patient will need psychotherapy to manage her stress and anxiety and provide instruction on coping skills.

Plan: In 90 days patient will have decreased symptoms of depression.

Patient will adhere to medication instructions of Wellbutrin 150mg and Vistaril 25 mg.

Instructed patient to call 911 for suicidal or homicidal thoughts. Patient verbalized understanding.

Patient referred to psychotherapy. Instructed patient to follow-up to ensure she is on schedule for psychotherapy.