case study: Mr. 37-year-old white male with history of alcohol intoxication

 

 

 

           

Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD

 

 

 

Student Name

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Assignment Due Date

 

 

 

 

 

 

 

 

 

 

 

SOAP Note for Anxiety, PTSD, and OCD

Subjective:

CC: “Psychiatric evaluation”

HPI: K.P is a 37-year-old white male who reported to the clinic accompanied by his father with a history of alcohol intoxication, alcohol use disorder, and a rule out of anxiolytic and sedative use disorder. The father reports that the patient is positive for auditory hallucination, arrogance, lack of sleep, and potential harm to self and others. His previous visit to the clinic was in April this year. The patient reports having a puncture wound to his arm via a nail earlier today and is requesting a tetanus shot. During the present visit, the patient denies having difficulties with sleep, being depressed, having low energy, or loss of appetite. He also denies suicidal ideation but confirms a history of suicidal attempts. He reports no history of anxiety or maniac episodes, paranoia, or homicidal ideation.

Past Psychiatric History:

• General Statement: The patient appeared guarded and slurred upon arrival at the clinic. He tried to commit suicide last year via Tylenol overdose.
• Caregivers (if applicable): The patient is currently under the care of his father who has been trying very hard to make him seek psychiatric treatment.
• Hospitalizations: The patient was hospitalized in Terrell State Hospital in May, Rusk in 2007, and repeatedly in Corsicana following his suicide attempt.
• Medication trials: Unknown.
• Psychotherapy or Previous Psychiatric Diagnosis: Alcohol intoxication and alcohol use disorder.

Substance Current Use and History: The patient reported to the psychiatric unit with a history of alcohol intoxication. Anxiolytic and sedative use disorders were ruled out. He tried to commit suicide the previous year via Tylenol overdose. Denies use of any other illicit drug of abuse.

Family Psychiatric/Substance Use History: The patient reports no family history of substance use disorder or any other mental illness that is known.

Psychosocial History: The patient was raised by both his parents. He however currently lives with his father, who has been trying very hard to get him treated. He is not married with no children. He reports a sedentary lifestyle, with inadequate sleep from depression.

Medical History: No history of chronic illness reported.

• Current Medications: Klonopin5 mg twice daily
• Allergies: No known drug, food, or environmental allergies.

• Reproductive Hx: The patient is with no history of reproductive disorders.

ROS:

CONSTITUTIONAL: No fever, weight gain, weight loss, chills, fatigue, or general body weakness.

EYES: No changes in visual acuity or blurred vision. Puts on corrective lenses only when reading. Lat eye exam was done a year ago.

EARS, NOSE, THROAT: No hearing problems, tinnitus, or ear pain. No epistaxis. No bleeding gums, sore throat, or toothache.

CARDIOVASCULAR: No chest pain, palpitations abnormal heartbeat, or decreased exercise intolerance.

RESPIRATORY: No breathing difficulties or dyspnea. Denies coughing, congestions, or hemoptysis.

GASTROINTESTINAL: No constipation, diarrhea, hernia, or abdominal tenderness. Denies changes in bowel movement.

GENITOURINARY: Reports urgency. Denies hesitation, polyuria, dysuria, oliguria, dribbling, or incontinence.

HEMATOLOGIC/LYMPHATIC: No anemia, easy bruising, or any other blood disorder.

ENDOCRINE: Denies heat or cold intolerance, sweating, changes in appetite, or hair loss.

NEUROLOGIC: No paralysis, syncope, dizziness, or headache.

PSYCHIATRIC: The patient presents with a history of alcohol intoxication and alcohol use disorder. No depression, hallucinations, or suicidal ideation.

Objective:

Vital Signs: Temperature 98.4, BP 132/86, HR 97, R 18, OS 97%, Ht 69, Wt 189.8, girth 39.

Labs, radiology, or other pertinent studies: Routine blood test, including CBC, WBC, and Hb, which are normal. Comprehensive metabolic panel and thyroid-stimulating hormones are normal. COVID test was negative.

 

 

Physical Exam:

General survey: The patient appeared guarded and somehow slurred during the assessment period. No headache, dizziness, loss of appetite, or weight changes.

PSYCHOLOGICAL: Seems sad with a history of alcohol intoxication and alcohol use disorder

HEAD: Normocephalic and symmetrical with no signs of rashes, lesions, or trauma.

EYES: PERRLA, and symmetrical with EOM’s full and white sclera. Clear conjunctiva was noticed bilaterally with no discharge.

EARS: Symmetric. External auditory canal pink and patent without edema, erythema, or excess cerumen. Normal tympanic membrane. Hearing is grossly intact.

NOSE: No external lesions noted, with normal mucosa that is non-inflamed. Normal turbinate and septum. THROAT/MOUTH: Clear with no lesions, exudates, or abnormal tongue movement.

LYMPHATIC/NECK: Supple with no lump or masses. CARDIOVASCULAR: S1, and S2 present with no murmurs, gallops, rubs, or clicks. Capillary refill < 3 sec. Bilateral and equal +2 pulses on palpation at the radial.

RESPIRATORY: Symmetrical chest. Non-diminished lung sounds without adventitious sounds. No wheezes, rhonchi, rales, or crackles were noted.

NEURO: Clear speech. Alert and oriented x 4. Unsteady gait and balance.

ABDOMEN/GI: No splenomegaly or hepatomegaly noted. No abdominal tenderness on palpation.

MUSCULOSKELETAL/EXTREMITIES: Exhibits full range of movement in both lower and upper limbs. Adequately aligned spine.

Assessment:

Mental Status Examination: The 37-year-old patient reported to the clinic appearing guarded and somehow slurred. He is however alert and oriented in person, place, and time. He seems sad and distracted with threats of wanting to kill everyone. He however cooperates during the interview in answering questions but in a rude tone. He is agitated. His affect is appropriate but dull. Thought the process is compromised. His father reports that the patient has been hearing voices, with sleeping problems and depression which the patient denies. Both his short-term and long-term memory are intact. His insight is appropriate. Confirm suicidal ideation with a history of suicidal attempts.

Differential Diagnosis:

1. Alcohol Use Disorder: The patient presented to the clinic with a history of alcohol intoxication, alcohol use disorder, and a rule out of anxiolytic and sedative use disorder. The patient meets the DSM-V criteria for this diagnosis based on his history of alcohol intoxication, and suicidal attempts via Tylenol overdose (Saunders et al., 2019). He also walked to the clinic in a slurred manner, even though he denies that he has not used any.
2. Oppositional Defiant Disorder: The patient further reported that he is stubborn and has even tried several times to get him to the psychiatric unit. He was also arrogant with the healthcare team during assessment claiming that he could kill every. The patient however fails to meet the diagnostic criteria as outlined by the DSM-V (Najafi et al., 2022)
3. Major Depressive Disorder: According to the DSM-V, a patient can only qualify for this diagnosis when they present with at least 5 of the following symptoms for the same 2 months, depressed mood, sleeping problems, psychomotor agitation, fatigue, loss of interest, worthlessness, and suicidal ideation (McHugh & Weiss, 2019). The patient denied most of these symptoms which disqualifies this diagnosis.

Reflection: Based on the provided information, the PMHNP did an excellent job in collecting adequate data from both the patient and his father to promote effective diagnosis and treatment. Despite the patient being an adult, with the legal right to make decisions concerning his health, he was reluctant to visit the clinic (Conner & Bagge, 2019). As such, his father can call for involuntary hospitalization, given that the patient has already displayed a history of suicidal attempts, and even threatens to kill everyone in his life.

Plan:

Diagnostic Studies: Urine drug test- positive for alcohol. Negative for anxiolytics and sedative-hypnotics.

Psychotherapy: Consider cognitive behavioral therapy and counseling to help with the patient’s alcohol use disorder (Jacob & Wang, 2020)

Pharmacotherapy: Administer metadoxine to manage the patient alcohol intoxication. Review the patient and consider non-pharmacological approaches for the management of the patient alcohol use disorder as recommended (Jacob & Wang, 2020).

Education: Advise the patient to stay compliant with the treatment regimen for a positive outcome.

Follow up: Admit the patient to the clinic level red for safety precautions clinic (Conner & Bagge, 2019).

 

 

References

Conner, K. R., & Bagge, C. L. (2019). Suicidal behavior: links between alcohol use disorder and acute use of alcohol. Alcohol research: current reviews, 40(1). DOI: 

Jacob, A., & Wang, P. (2020). Alcohol intoxication and cognition: implications on mechanisms and therapeutic strategies. Frontiers in neuroscience, 14, 102.  

McHugh, R. K., & Weiss, R. D. (2019). Alcohol use disorder and depressive disorders. Alcohol research: current reviews, 40(1). DOI: 

Najafi, K., Mikaeili, K., & Yousefi, F. (2022). Predictor factors of attention-deficit/hyperactivity, conduct, and oppositional defiant disorders in children of parents with drug abuse. Chronic Diseases Journal, 10(2). DOI: 

Saunders, J. B., Degenhardt, L., Reed, G. M., & Poznyak, V. (2019). Alcohol use disorders in ICD‐11: Past, present, and future. Alcoholism: Clinical and experimental research, 43(8), 1617-1631.