Mental Health Disorders in Adolescents Essay

Mental Health Disorders in Adolescents Essay

 

SOAP Note

 

SUBJECTIVE DATA:

Chief Complaint (CC): “My PCP wants me to have follow up with psychiatrist.”

History of Present Illness (HPI): MB who is currently a student at the University of MD was referred by her PCP for evaluation and treatment of underlying anxiety disorder. She suffers from anxiety all her life but noticed lately an increase in the severity of symptoms of anxiety making it difficult for her to concentrate and focus. She gets worried too much about little things, worried about health issues. she also suffers social anxiety and avoids contact with new people including meeting with her friends as she has to prepare and pump herself. Currently, she is having a summer break hence not under any kind of stress.

Past Medical History (PMH): She had abdominal issues in December but all the work up done were normal. Denies history of diabetes or hypertension.

Medications: Currently not taking any medications.

Allergies: No known food and drug allergies

Family and Social History: Last born in a family of two. A university student. She denies smoking tobacco or taking alcohol. No family history of psychiatric disorders

Health-Related Behaviors: Visits her PCP after every three months. Adheres to a balanced diet.

Review of Systems:

General: Reports fatigue but denies hotness of the body, chills, nausea and vomiting, and generalized body malaise

Respiratory: She denies cough, difficulty in breathing, or cough.

Cardiovascular: Reports occasional awareness of the heartbeat. Denies cough, syncope, or chest pains.

Gastrointestinal: She denies diarrhea, loss of appetite, abdominal pain, and dysphagia

Psychiatric: Denies anxiety attack, panic attack, history of depression, mood swings, mania, delusion, or obsessive-compulsive disorder.         

OBJECTIVE DATA:

Physical Exam:

Vital signs: BP 125/80 mmHg, temperature 98 F, HR 80bpm, RR 19 breaths/ min., saturation- 95% on room air.

General: A young adult Caucasian female, in a fair general condition, well-kempt, well-hydrated, good nutrition status, no respiratory distress. No conjunctival or palmar pallor, jaundice, central cyanosis, peripheral limb edema, and cervical or inguinal lymphadenopathy

Mental State Examination:  A young adult Caucasian female, appropriate for age, alert, well-kempt, avoids eye contact, anxious, and tensed. Oriented to time place and person. Soft, coherent, and spontaneous speech, appropriate mood, stable affect, easily distracted, intact memory, logical thought process, phobias but no delusions or suicidal ideations. No hallucinations. Good insight and judgment.

Chest/Lungs: Symmetrical, resonant. Vesicular breath sounds.

Cardiovascular: Normoactive precordium, S1 S2 heard, no murmur, apex beat in the 5^th intercostal space midclavicular, no heaves, and no thrills.

ASSESSMENT:

Main Diagnosis: The principal diagnosis of her condition is likely to be social anxiety disorder- MB reports suffering from social anxiety and avoids contact with new people including her friends without prior preparation (DSM-5, 2013). Her fear cannot be better explained by another mental, substance use, or medical disorder. Furthermore, these symptoms have interfered with her functioning (Penninx et al., 2021).

Differential Diagnosis

Generalized anxiety disorder. MB meets the DSM-5 criteria for diagnosis of generalized anxiety disorder. For instance, her symptoms have been present for more than 6 months, she has concentration difficulties, she is tensed, reports fatigue, worried over too many little things (DSM-5, 2013). Similarly, her symptoms are not due to substance or medication-induced and have caused a significant impairment in functioning (Ströhle et al., 2018). Other differential diagnoses that may be considered include illness anxiety disorder. She states that she had previously had an abdominal issue and thought something really bad with her stomach. However, all the workups were normal. Other causes of anxiety such as hyperthyroidism, asthma, atrial fibrillation, DKA, and substance abuse can also be considered as differentials.

Generalized anxiety and social anxiety disorders are variants of anxiety disorders. Anxiety disorders can stem from neurobiological factors including disruption of the serotonin system and dysfunction of the GABAergic inhibitory system. Substance use, medical disorders such as hyperthyroidism, and environmental factors such as stress, smoking, and psychological trauma are other causes of anxiety (Chand & Marwaha, 2022). Genetic vulnerability further interacts with these factors to produce clinically significant anxiety.

PLAN:

• Thyroid function tests to rule out hyperthyroidism, a known cause of anxiety.
• Complete blood count, random blood glucose, lipid profile, liver function tests, urea, creatinine, and electrolytes to establish a baseline for pharmacologic management.
• Psychotherapy particularly cognitive behavioral therapy. According to Ströhle et al. (2018), cognitive-behavioral therapy should be considered the first line option for the management of both social anxiety and generalized anxiety disorders. It is usually conducted for about ten to fifteen sessions (Springer et al., 2018). Additional techniques include applied relation therapy and biofeedback.
• Medications: selective norepinephrine reuptake inhibitor i.e., venlafaxine extended-release capsules- 75 mg once daily. Treatment duration may be up to 12 months. Adverse effects include neuroleptic malignant syndrome, suicidal thoughts, serotonin syndrome, abnormal dreams, sexual dysfunction, altered taste, abdominal pain, and visual disturbances (Penninx et al., 2021). Should be used in combination with CBT.
• Monitoring- monitor blood pressure, assess for suicidal risk, check blood glucose, complete blood count, liver function tests, and UECs periodically (Chand & Marwaha, 2022). Desired outcomes include decreased anxiety, increased sense of well-being, and renewed interest in surroundings.
• Patient education- take medication as prescribed, look for suicidality, avoid driving as the drug causes dizziness and drowsiness, and inform the healthcare provider of signs of allergy, before taking other medications and if planning pregnancy (Chand & Marwaha, 2022).
• Follow-up exams to monitor progress.

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References

Chand, S. P., & Marwaha, R. (2022). Anxiety. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470361/

DSM-5. (2013). Psychiatry.org. https://psychiatry.org/psychiatrists/practice/dsm

Penninx, B. W., Pine, D. S., Holmes, E. A., & Reif, A. (2021). Anxiety disorders. Lancet, 397(10277). https://doi.org/10.1016/s0140-6736(21)00359-7

Springer, K. S., Levy, H. C., & Tolin, D. F. (2018). Remission in CBT for adult anxiety disorders: A meta-analysis. Clinical Psychology Review, 61, 1–8. https://doi.org/10.1016/j.cpr.2018.03.002

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Arzteblatt International, 155(37), 611–620. https://doi.org/10.3238/arztebl.2018.0611

 

MB 27 years old marriage Caucasian female came to the clinic stated MY PCP WANTS ME TO HAVE FOLLOW UP WITH PSYCHIATRIST
MB WHO IS CURRENTLY STUDENT AT UNI OF MD WAS REFERRED BY PCP FOR EVALUATION AND TREATMENT OF UNDERLYING ANXIETY DISORDER

AS PER PT SHE SUFFER WITH ANXIETY ALL HER LIFE BUT NOTICED LATELY SYMPTOMS OF ANXIETY WERE WORSE THAT IT WAS DIFFICULT FOR HER TO CONCENTRATE AND FOCUS
AND STILL GETS WORRIED TOO MUCH FOR LITTLE THINGS
WORRIED ABOUT HEALTH ISSUES

IN DEC SHE HAD ABDOMINAL ISSUES AND THOUGHT SOMETHING REALLY BAD WITH HER STOMACH HAD ALL THE WORK UP DONE WAS NORMAL .
SHE ALSO SUFFER WITH SOCIAL ANXIETY AVOIDS TO CONTACT WITH NEW PEOPLE EVEN TO MEET WITH FRIENDS SHE HAS TO PREPARE AND PUMP SELF

NO ANXIETY ATTACK NO PANIC ATTACK
CLAIMS CURRENTLY SHE IS HAVING SUMMER BREAK SO NOT IN ANY KIND OF STRESS

NO HISTORY OF DEPRESSION, MOOD SWINGS , NO MANIA, NO OCD, NO DELUSION.

Upon your assessment write SOAP NOTE, make a Diagnosis based on DSM-5 and Treatment Plan: Definitive diagnosis, Differential diagnosis: and Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors); Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up).