Nurs680 Week 2 Discussion Question

Nurs680 Week 2 Discussion Question

The case involves a 52-years old woman who complains of missing days at work almost every week. Furthermore, she neglects the family and has changed her sleeping patterns. She denies other health problems and environmental allergens. Therefore, screening needs to be done for suicide risk and depression. The purpose of this assignment is to create suicide risk and depression questions, and formulate a SOAP note for this case.

Additional Questions

Some of the questions to ask the patient include:

1. Have you lost interest in things you used to find pleasurable before?
2. Do you feel down and depressed?
3. Do you feel tired and fatigued?
4. Have you ever thought that you would be better dead or even hurt yourself?
5. Do you have trouble concentrating on the activities of daily living?
6. Have you ever thought of killing yourself?

Subjective Data

The patient indicates that she feels fatigued and has lost interest in the activities she used to find fun before. She likes being alone and easily gets irritated. She stated that she felt safe being alone and not being disturbed by anybody. Also, she indicated that she had trouble concentrating on one task and this would affect her ability to engage in the activities of daily living. On the other hand, she denies being suicidal. She indicated that while her current situation was not the best, she was optimistic that things would get better. Furthermore, she was more concerned that she would lose her job considering that she had been absent often.

Objective Data

The patient was restless and worried. The vitals were normal, B.P 126/78mmHg, PR-75bpm, Wt: 156 pounds, Ht: 5’4’’, BMI: 24.5. The ROS indicates that there was no cyanosis or edema in the extremities. The assessment on the abdomen showed that it was non-distended and non-tender. The patient had normal ROM. No murmur or gallops were noticed on the review of the heart. The lungs were CTA bilaterally. The skin was well moisturized with no lesions, bruises, or signs of injuries.

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Assessment

Pertinent Positive and Negative: The pertinent positives included feeling tired and fatigued. Also, she isolates herself from the rest of the family members (Kalin, 2020). She lost interest in the things she used to enjoy before. On the other hand, the pertinent negatives include a lack of suicidal ideation.

Primary Diagnosis: The primary diagnosis is major depressive disorder with no suicidal ideation. Major depressive disorder is characterized by feeling fatigued and worthless (Kalin, 2020). The patients also lose interest in the things they used to enjoy and this makes it the most preferable diagnosis for the patient. The patient had chronic low mood and lost interest in things she used to love. The diagnosis developed was depression because of low energy and restlessness presented by the patient.

Differential Diagnoses: The differential diagnoses based on the patient’s clinical manifestations include generalized anxiety disorder (GAD) and hypothyroidism. The patient could be having GAD because she is anxious and worried about her job. Hypothyroidism is a differential diagnosis based on the patient’s symptom of low energy levels and sleepiness.

Plan

Test to be ordered: The plan is to perform a complete blood count and thyroid function test to rule out hypothyroidism and any other underlying condition.

Treatment Plan: The treatment plan will include initiating the patient on fluoxetine 10mg OD. The patient will be reviewed for two weeks. In case the symptoms persist, the dose administered will be increased to 20mg OD (Capitão et al., 2019). The patient willalso be enrolled in psychotherapy sessions. The need to engage in regular physical exercise and be socially active will be emphasized as part of patient education and lifestyle modification. The age-specific preventive care will include engaging in social activities to nourish her spiritual connectedness.

Follow-up: A follow-up visit will be scheduled after two weeks to assess the client’s response to treatment and adjust the treatment plan of necessary.

Conclusion

The signs and symptoms presented by the patient suggest that she has a major depressive disorder. Therefore, the treatment plan focused on managing the depressive symptoms and helping the patient regain her energy. The treatment may be adjusted based on the lab test results.

References

Capitão, L. P., Chapman, R., Murphy, S. E., Harvey, C., James, A., Cowen, P. J., & Harmer, C. J. (2019). A single dose of fluoxetine reduces neural limbic responses to anger in depressed adolescents. Translational Psychiatry, 9(1). https://doi.org/10.1038/s41398-018-0332-2

Kalin, N. H. (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365-367. https://doi.org/10.1176/appi.ajp.2020.20030305

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A 52-year-old woman complains that she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night. She denies other health problems, medication, or environmental allergies.
Suicide risk and depression screening.

Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list: A SOAP note is: Subjective- What the patient says to you during question and answers.
Objective- Observed, notice, or found on exam. Assessment- Diagnose and justify.
Plan- Test to be order. Referral to specialist, discharge instruction/ Education given to the patient, Medication/ follow-up visit.
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.