Please use the infor below to writer an expanded SOAP note. I attached a file wi
Please use the infor below to writer an expanded SOAP note. I attached a file with instructions on the required informations and another file that’s a sample of a completed expanded SOAP note. Please make up an required information that is missing for the patient information provided below.
Reason for admission:
Patient was admitted due to concerns about depression and suicidal thoughts.
HPI:
55 year old female
Patient states that she has had no prior treatment for depression until recently. She has no prior hospitalizations for mental health.
Patient reports that she has had some depression in the past but denies that there has ever been an episode of extended depression. She has also never had an episode of mania or hypomania.
Patient reports that she has had more depression that corresponds to worsening health symptoms. She developed fatigue and weakness that worsened enough that she sought out medical care. She did test positive for covid at that time. One month ago she developed substantial neuropathy in her lower legs and arms. This was described as pins and needles. She was started on Neurontin which helps but she still has the neuropathy and it waxes and wanes.
Patient has been very discouraged by this and has developed substantial depression.
Patient developed more suicidal thoughts over the past 3-4 weeks. Her family got more concerned by this, especially since she was making videos that they interpreted as good-bye videos.
Patient states that did have thoughts of shooting self.
Today patient states that she does not believe she would carry out a suicide because of her family and her religion. She denies suicidal thoughts today. She does report depressed mood.
She has no evidence of psychosis.
Patient was placed on hold in the Emergency room, but now is willing to stay voluntary.
According to ER report:
HPI
Tina Logan is a 55 year old female with a history of hypothyroidism, HLD, and asthma who presents to the emergency department for evaluation of suicidal ideations. She reports that over the past two months, starting mid-May she has had increasing thoughts of ending her own life. She feels as though he depression has getting more severe. She has no history of suicidal ideation prior to the past couple of months, and no previous history of suicide attempts. She is having thoughts of making a plan, and has had thoughts of shooting herself with a fire arm or jumping off a roof. She has actively called hotels in the area to see if they have a roof she can have access to in order to carry out her plan. She also made goodbye videos within the past week in preparation for potential suicide attempt. She is not having any auditory or visual hallucinations, and no drug or alcohol use. She has not been admitted to the hospital previously for mental health concerns, although she believes that her family would like her to be. She has not engaged in any self harm behavior, and just endorses suicidal ideations at this time. Her mother is at bedside with her.
MDM
This is a 55 year old female with a history of hypothyroidism presents to the emergency department with a complaint of suicidal ideation. Patient reports that she has struggled with depression for several months, and she feels like it is worsening. She denies any homicidal ideation. Denies any daily drug or alcohol use. She does have a plan, which would be to shoot herself, or jump off the roof of a building. The patient has been taking actions to call hotels to see which one might have a roof that she could jump off of.
On exam patient is calm and cooperative. She does not have any other complaints at this time.
I think with the patient having suicidal ideation, with a specific plan, and actually taking actions to seek out a roof to jump off of that she will need to be held in the emergency department until her mental health team can speak with her. HOA is placed, DEC orders placed. Mental health boarding order set is also placed.
Patient spoke with DEC, they would recommend inpatient placement. They state that the patient is borderline holdable. At this point I do not feel that the patient is safe to go home. She has active suicidal thoughts with plans, and is acting on some of them. It is very concerning. I did place a 72-hour hold on the patient. I did let the patient know, and she states that she does not want to stay. Patient states that she would like a room with a window. I did advise her that none of the exam rooms in the emergency department have windows. Patient is on the list for inpatient psych.
According to DEC assessment done in ER:
Referral Data and Chief Complaint
The patient presents to the ED with family/friends (with mother). Patient is presenting to the ED for the following concerns: Depression, Suicidal ideation, Anxiety. Factors that make the mental health crisis life threatening or complex are: Pt presents to the ED with her mother for worsening suicidal ideation with specific plans and recent preparatory behavior. Upon assessment, pt tells this writer that she contracted COVID in May 2024 and has seen multiple specialists for health concerns since then, including fainting, weakness, fatigue, and a “pins and needles” sensation in her arms and legs. She has been assessed by endrocrinology, gastroenterology, and neurology and has been seen in the ED 10 times since 05/29/24. Pt lives in Georgia with her husband and children but flew to Minnesota 3-4 weeks ago to receive support from her parents. Pt tells this writer that she does not know if she is going survive “this illness” and is afraid that she will die. Pt describes her current mood as “weepy and depressed”. She has been averaging about 2 hours of sleep per night for the past month due to racing, ruminating thoughts and estimates that she lost 18-19 pounds since May. She is also experiencing daily suicidal thoughts that last for hours on end to shoot herself or jump off of a tall building. She tells this writer that she knows that she is going to heaven and that it would be easiser to end her life now than live with her current pain. Within the past 1-2 weeks, she has called hotels to find out which ones have roofs that she can jump from and has asked her family to take her to the gun range. She does not have access to firearms at home. She has also filmed goodbye videos on her phone for her parents, husband, and children. She tells this writer that she filmed these videos in the event that she does not survive her “illness” rather than filming them in anticipation of completing suicide. She has been experiencing recurrent panic attacks with accompanying hyperventilation with most recent episode on 7/15 or 7/16. She denies HI or SUD..
Informed Consent and Assessment Methods
Explained the crisis assessment process, including applicable information disclosures and limits to confidentiality, assessed understanding of the process, and obtained consent to proceed with the assessment. Assessment methods included conducting a formal interview with patient, review of medical records, collaboration with medical staff, and obtaining relevant collateral information from family and community providers when available. : done
Patient response to interventions: eager to participate, needs reinforcement (Pt willingly engaged in a conversation with this writer about her mental health concerns but was hesitant about inpatient hospitalization.)
Coping skills were attempted to reduce the crisis: Pt has been seeking support from her parents and husband.
History of the Crisis
Pt tells this writer that she has a limited psychiatric history to date but that her father has a history of depression. She has no history of NSSI, suicide attempts, or inpatient psychiatric hospitalizations. She has had three sessions with a therapist based out of Lakeville, MN. Her primary care provider in Georgia started her on Lexapro about 4 weeks ago.
Brief Psychosocial History
Family: Married, Children yes (Pt has 4 sons.)
Support System: Parent(s), Husband
Employment Status: other (see comments) (pt is not working at present)
Source of Income: other (see comments) (family support)
Financial Environmental Concerns: none
Current Hobbies: outdoor activities, family functions
Barriers in Personal Life: mental health concerns, emotional concerns
Significant Clinical History
Current Anxiety Symptoms: panic attack, racing thoughts, excessive worry, shortness of breath or racing heart, anxious
Current Depression/Trauma: sense of doom, difficulty concentrating, negativistic, crying or feels like crying, low self esteem, impaired decision making, helplessness, hopelessness, sadness, thoughts of death/suicide
Current Somatic Symptoms: racing thoughts, excessive worry, shortness of breath or racing heart, anxious
Current Psychosis/Thought Disturbance:
Current Eating Symptoms: recent weight loss (Pt estimates losing 18-19 pounds since May 2024.)
Chemical Use History: Alcohol: None
Benzodiazepines: None
Opiates: None
Cocaine: None
Marijuana: None
Other Use: None
Past diagnosis: No known past diagnosis
Family history: Depression (Pt’s father has depression.)
Past treatment: Individual therapy, Primary Care
Details of most recent treatment: Pt has seen a therapist based out of Lakeville, MN for three sessions so far. Her primary care provider started her on Lexapro about 4 weeks ago.
Other relevant history: No other relevant history.
Collateral Information
Is there collateral information: Yes
What happened today: Pt’s family decided to bring her to the ED for worsening suicidal ideation.
What is different about patient’s functioning: Pt has been experiencing worsening physical health concerns that have negatively affected her mental health. She believes that she is not going to survive these physical health concerns, which has led to suicidal thoughts. She has suicidal plans to jump off of a building or shoot herself with a firearm. She does not own a firearm but recently asked to go a to a gun range. She also recently filmed videos within the last 1-2 weeks on her phone for her family to see when she dies. Rich states that pt’s family has essentially been on “suicide watch” due to concerns for pt’s mental health. He notes that pt has also not been eating or sleeping. Rich is requesting inpatient psychiatric hospitalization for pt.
Concern about alcohol/drug use: No SUD concerns.
Clinical Summary and Substantiation of Recommendations
It is the recommendation of this writer that pt be admitted to an inpatient psychiatric unit on the basis of her specific suicidal plans to shoot herself or jump off of a building. She does not have access to firearms. She has been engaging in preparatory behaviors, including asking to go to a gun range, calling hotels to see which ones have roofs to jump off of, and filming goodbye videos for her family. Pt believes that she is going to die due to her current physical health concerns and that it would be “easier to go to heaven” now than to live with the pain. Pt was requesting to discharge and attending provider decided to place pt on a 72 HH, which expires on 7/25/24 at 15:17.
Past Psychiatric History:
Patient was started on Lexapro recently, but had no prior treatment before this.
Substance Use and History:
Denies alcohol and drugs
Past Medical History:
PAST MEDICAL HISTORY:
Past Medical History
No past medical history on file.
Recent onset of fatigue, possible long Covid and Neuropathy
PAST SURGICAL HISTORY:
Past Surgical History
No past surgical history on file.
Family History:
FAMILY HISTORY:
Family HistoryExpand by Default
No family history on file.
Social History:
Please see the full psychosocial profile from the clinical treatment coordinator.
SOCIAL HISTORY:
Social History
Tobacco Use
• Smoking status: Not on file
• Smokeless tobacco: Not on file
Substance Use Topics
• Alcohol use: Not on file
PTA Medications:
Prescriiptions Prior to Admission
Medications Prior to Admission
Medication Sig Dispense Refill Last Dose
• albuterol (PROAIR HFA/PROVENTIL HFA/VENTOLIN HFA) 108 (90 Base) MCG/ACT inhaler Inhale 2 puffs into the lungs every 6 hours as needed for shortness of breath, wheezing or cough
• escitalopram (LEXAPRO) 10 MG tablet Take 10 mg by mouth every morning
• fenofibrate (TRIGLIDE/LOFIBRA) 160 MG tablet Take 1 tablet by mouth daily
• gabapentin (NEURONTIN) 100 MG capsule Take 100 mg by mouth at bedtime Take with 300mg capsule at bedtime.
• gabapentin (NEURONTIN) 300 MG capsule Take 1 capsule (300 mg) by mouth 3 times daily 30 capsule 0
• levothyroxine (SYNTHROID/LEVOTHROID) 125 MCG tablet Take 125 mcg by mouth daily
Current Medications:
Inpatient Administered Meds
No current facility-administered medications for this encounter.
Inpatient Meds PRN
No current facility-administered medications for this encounter.
Allergies:
Allergies
Allergies
Allergen Reactions
• Grass Headache
Labs:
Recent Results
Recent Results (from the past 72 hour(s))
Basic metabolic panel
Collection Time: 07/22/24 3:11 PM
Result Value Ref Range
Sodium 142 135 – 145 mmol/L
Potassium 4.5 3.4 – 5.3 mmol/L
Chloride 106 98 – 107 mmol/L
Carbon Dioxide (CO2) 27 22 – 29 mmol/L
Anion Gap 9 7 – 15 mmol/L
Urea Nitrogen 12.5 6.0 – 20.0 mg/dL
Creatinine 0.89 0.51 – 0.95 mg/dL
GFR Estimate 76 >60 mL/min/1.73m2
Calcium 9.2 8.8 – 10.4 mg/dL
Glucose 140 (H) 70 – 99 mg/dL
CBC with platelets and differential
Collection Time: 07/22/24 3:11 PM
Result Value Ref Range
WBC Count 7.6 4.0 – 11.0 10e3/uL
RBC Count 4.69 3.80 – 5.20 10e6/uL
Hemoglobin 12.6 11.7 – 15.7 g/dL
Hematocrit 40.8 35.0 – 47.0 %
MCV 87 78 – 100 fL
MCH 26.9 26.5 – 33.0 pg
MCHC 30.9 (L) 31.5 – 36.5 g/dL
RDW 14.5 10.0 – 15.0 %
Platelet Count 389 150 – 450 10e3/uL
% Neutrophils 65 %
% Lymphocytes 23 %
% Monocytes 8 %
% Eosinophils 3 %
% Basophils 1 %
% Immature Granulocytes 0 %
NRBCs per 100 WBC 0 <1 /100
Absolute Neutrophils 4.9 1.6 - 8.3 10e3/uL
Absolute Lymphocytes 1.8 0.8 - 5.3 10e3/uL
Absolute Monocytes 0.6 0.0 - 1.3 10e3/uL
Absolute Eosinophils 0.2 0.0 - 0.7 10e3/uL
Absolute Basophils 0.1 0.0 - 0.2 10e3/uL
Absolute Immature Granulocytes 0.0 <=0.4 10e3/uL
Absolute NRBCs 0.0 10e3/uL
Extra Blue Top Tube
Collection Time: 07/22/24 3:11 PM
Result Value Ref Range
Hold Specimen JIC
Extra Red Top Tube
Collection Time: 07/22/24 3:11 PM
Result Value Ref Range
Hold Specimen JIC
Urine Drug Screen Panel
Collection Time: 07/22/24 4:54 PM
Result Value Ref Range
Amphetamines Urine Screen Negative Screen Negative
Barbituates Urine Screen Negative Screen Negative
Benzodiazepine Urine Screen Negative Screen Negative
Cannabinoids Urine Screen Negative Screen Negative
Cocaine Urine Screen Negative Screen Negative
Fentanyl Qual Urine Screen Negative Screen Negative
Opiates Urine Screen Negative Screen Negative
PCP Urine Screen Negative Screen Negative
Asymptomatic COVID-19 Virus (Coronavirus) by PCR Nasopharyngeal
Collection Time: 07/22/24 4:58 PM
Specimen: Nasopharyngeal; Swab
Result Value Ref Range
SARS CoV2 PCR Negative Negative
Physical Exam:
BP 119/81 (BP Location: Left arm, Patient Position: Sitting, Cuff Size: Adult Regular) | Pulse 71 | Temp 97.8 °F (36.6 °C) (Oral) | Resp 16 | Ht 1.803 m (5' 11") | Wt 85.5 kg (188 lb 7.9 oz) | SpO2 95% | BMI 26.29 kg/m²
Weight is 188 lbs 7.89 oz Body mass index is 26.29 kg/m².
Physical Exam:
Gen: No acute distress
Skin: No diaphoresis or rash
Neuro: No abnormal movements
Physical ROS:
The patient endorsed Neuropathy in arms and legs. The remainder of 10-point review of systems was negative except as noted in HPI.
Mental Status Exam:
Mental Status
Patient is casually dressed
Hygiene good
Speech fluent
Thought Process logical
Thought Content: No suicidal ideation today,
No homicidal ideation,
No ideas of reference,
No loose associations,
No auditory hallucinations,
No visual hallucinations
No delusions
Psychomotor: No agitation or slowing
Cognition: Alert and oriented to time place and person
Attention good
Concentration good
Memory normal including recent and remote memory
Mood: depression
Affect: mood congruent
Judgement: normal
Eye contact good
Cooperation good
Language normal
Fund of knowledge normal
Musculoskeletal normal gait with no abnormal movements
Diagnoses:
Severe major depression, single episode, without psychotic features (H)
Patient Active Problem List
Diagnosis
• Depression
• Anxiety
• Acquired hypothyroidism
• Asthma
• Borderline diabetes
• Diarrhea
• Hyperlipidemia
• Internal derangement of right knee
• Primary osteoarthritis of right knee
• Vitamin D deficiency
• Depression with suicidal ideation
Assessment:
Patient presents with substantial depression that appears to be provoked by fatigue, neuropathy of unknown etiology but possible Long Covid.
Plan:
Legal:
Patient is willing to stay voluntary so will discontinue hold and switch to voluntary status
Medication: Will gradually increase Neurontin which will hopefully be more helpful for Neuropathy as well as anxiety.
Will also gradually cross titrate from Lexapro to Cymbalta but will only change one medication in any day, due to her substantial anxiety about medication changes.
Consults: Hospitalist will be consulted if medical issues arise
Multidisciplinary Interventions: Social Services to gather collateral information, coordinate care with outpatient providers and begin follow up planning
Disposition:
Home with follow up