Week 7: SOAP Note Student Name College of Nursing-PMHNP, Walden University PRAC 6665: PMHNP Care Across the Lifespan I Dr. Michelle Pinckney Date: …. SUBJECTIVE Initials: K.M. CC: “I am so depressed. Nothing has worked for me.” HPI: The client is a 69-year-old female referred for esketamine treatment for her major depressive disorder. After multiple treatment failures, she has decided to try esketamine treatments. She has a longstanding history of major depressive disorder and idiopathic hypersomnia. She reports feeling depressed in the morning immediately upon wakening, stating, “I just don’t want to get out of bed. I have to push myself.” She finds herself having poor concentration, lacking energy and motivation to do anything during the day. She cannot finish tasks around her home and states, “I will start things but then just can’t seem to finish them.” She has lost touch with her friends, and since Covid has stopped volunteering at the animal shelter where she rescued her two dogs. She spends most of her concentrating on factors that depress her at home. She has been diagnosed with hypothyroidism and multiple sclerosis, which has left her with some gait issues, requiring a cane for ambulatory assistance. Today she rates her depression 7/10 and denies anxiety, stating, “I am never anxious, just always depressed.” She denies suicidal ideations, homicidal ideations, auditory and visual hallucinations. Psychiatric History: The client has been diagnosed with major depressive disorder, recurrent around age 27. She has no history of previous inpatient hospitalizations. She has attended intensive outpatient therapy in 2005, 2017, and 2021. She received transcranial magnetic stimulation iin April 2021. She is currently going to psychotherapy weekly and has been doing individual psychotherapy since the late ’90s. She denies suicide attempts in her lifetime. She states, “I have had suicidal thoughts. Medication Trials •Abilify •Lexapro •Effexor She reports the failed medication trials were all due to lack of effectiveness with her symptoms. She denies adverse events except on Abilify, she reports fine tremors. Current Medications: •Prozac 40 mg by mouth daily r •Spravato 84mg intranasally once weekly (administered in 3 separate doses over 15 minutes) for depressive disorder •Focalin XR 3omg daily by mouth daily •Wellbutrin XL 450mg by mouth daily •Levothyroxine 112 mcg by mouth daily. Take one hour before breakfast. Family Psychiatric/Substance Abuse Mother- alcohol abuse Brother-alcohol abuse Maternal Aunt-depression Paternal Uncle-depression and suicide attempt Substance Current Use: Client reports no past or present tobacco use, use of illicit substances or alcohol use. She reports no history of drug tolerance or withdrawal symptoms from substances. Legal Issues: None Medical History: •Hypothyroidism, unspecified (diagnosed 1999) (E03.9) •Multiple Sclerosis (diagnosed 1994) (G35) •Idiopathic hypersomnia (G47.12) Allergies: sulfonamide antibiotics-rash Reproductive Hx: oPost-menopausal oNo reproductive history; no children oNo currently sexually active Psychosocial History The client is a divorced Caucasian female who grew up in a home raised by her mother and father. She reports having a sister, ages 61, and a brother, age 56. She reports she is close with her sister but states, “I am not close with my brother. He is an alcoholic.”.......... Continue