Week 9: Focused Soap note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
PRAC 6635: Psychopathology and Diagnostic Reasoning
CC (chief complaint): “Iwant to die, if I don’t get my pain medications”.
HPI: Patient (D.J.) is a 29-year-old, white, Hispanic male, unmarried, presented to JBHH-ED by LEO for suicidal ideation. The patient originally went voluntary to the medical hospital asking for Dilaudid due to pain. Patient said he received 8 gunshot in2016 in chest/abdomen and legs related to gang violence. During the interview with the patient, he admitted that he was injecting fentanyl for pain and now is having symptoms of withdrawal. Patient had a lose stool if front of me and he is requesting pampers. Patient reports is living with his aunt. The patient endorses psychiatric symptoms of opioid withdrawal. The patient has history of several hospitalizations for Opioids usage.
Past Psychiatric History:
- General Statement: Patient started using opioids after 8 GSW to chest/abdomen/leg. He initially started with Oxycodone 6-7 pills daily, starting Oxycodone months ago which he receives form a friend, and currently has been injecting 1 gram of fentanyl daily for this year. He has tried Suboxone which had helped him with cravings. Patient states he is prepared and determined to quit. He is currently interested in going to an outpatient program. Patient is currently being tapered off of alprazolam which he has taken since 2021 for anxiety and PTSD.
- Caregivers (if applicable): Mother
- Hospitalizations: Patient had multiple hospital admissions for low mood and was at a rehab facility after GSW. He has been taken pain medications since the gunshot wound. Patient has been placed into 4 residential Rehab programs in the past which was not successful.Patient is now agreeable to go to another inpatient Rehab again. He denies having any death wishes/plan/intent at the time of this assessment.
- Medication trials: Alprazolam 1mg Oral, TID; Buprenorphine 8mg Tab, Sublingual BID
- Psychotherapy or Previous Psychiatric Diagnosis: The patient was previously diagnosed with PTSD, Schizophrenia, Anxiety, and Opioid abuse. The patient was once sent to a rehab program result was not successful.
Substance Current Use and History:
The patient reports daily usage of Fentanyl since at the age of 20. Patient has been taking Dilaudid for his chronic back pain since his gunshot wound in 2016. Patient denies any alcohol usage. Denies smoking nicotine and denies any other illicit drugs. Patient can be seen going through withdrawals at his time as evidence by current diarrhea.
Family Psychiatric/Substance Use History:
The patient reports that his father did not used any drugs or have any psychiatric illness. His mother suffers from depression. Patient is living with his mother and father his father. Denies family substance abuse and denies family medical problems.
Psychosocial History: This patient was born in Hialeah, Florida, and he is currently living with his mother. Pt has a hx of opiate abuse and stimulant abuse. Previously attended rehab in the past. Reported using the following substances: Dilaudid and Fentanyl “alot” but daily, for pain. Reported starting drug usage after when he was shot in 2016. Patient did not finish high school. He was working as a computer engineer, but stop working after the accident.
Medical History:
- Current Medications:
ALPRAZolam 2 mg oral tablet 2 mg = 1 tab, PRN, ORAL, TID
Baclofen 20 mg oral tablet 20 mg = 1 tab, ORAL, TID,
Gabapentin 600 mg oral tablet 600 mg = 1 tab, ORAL, TID,
Percocet 5 mg-325 mg oral tablet 1 tab, ORAL, Q6H
- Allergies: Iodine; Nuts; Lovenox; Toradol
- Reproductive Hx: Male, no children
ROS:
- GENERAL: Alert, Awake X 4
- HEENT: Pupils are equal, round and reactive to light, extraocular movements are intact. Oral mucosa moist. Normocephalic, atraumatic
- SKIN: Warm, Denies rash, Denies swelling, Denies lacerations, Denies abrasions
- CARDIOVASCULAR: Regular rate and rhythm
- RESPIRATORY: Lungs are clear to auscultation, no tenderness
- GASTROINTESTINAL: Denies nausea, Denies vomiting, Denies diarrhea, Denies constipation, Denies bloating, Denies melena
- GENITOURINARY: Denies Dysuria, Denies frequency, Denies flank pain, Denies hematuria
- NEUROLOGICAL: Alert and oriented to person, place, time, and situation. No focal neurological deficit observed.
- MUSCULOSKELETAL: Normal ROM.
- HEMATOLOGIC: No bruising, No petechiae, No bleeding noted
- LYMPHATICS: Denies any swollen nodes
- ENDOCRINOLOGIC: Denies polyuria, Denies polydipsia, Denies polyphagia
Physical exam: No physical exam is required at this time.
Diagnostic results: TSH, CPM, BMP, CBC, and labs would be performed to rule out any psychiatric symptoms related to medical conditions. The Mood questionnaire would be provided to the patient to assess for bipolar disorder.
Assessment:
Mental Status Examination:
Patient is 29 years white, Hispanic male evaluated today, patient reports in moderate distress 2/2 to w/d and with poor eye contact, minimally conversation. Patient reporting moderate sx of w/d including muscle aches, nausea, restless, chills. ToleratedSubutex and amenable to continue Subutex for detox and motivated to stay on maintenance dose.The patient endorses psychiatric symptoms of opioid withdrawal, resting pulse <80, yawning, restlessness, pupil size normal size for room light without pathologic dilation, bones or joint aches, no rhinorrhea, tremor, no gooseflesh, anxiety, irritability, GI upset, no sweat, COWS=14. Patient states he also has a dx of PTSD and prescribed Alprazolam 2mg TID by outpatient psych. per patient information he was last prescribed alprazolam 1mg TID. Pt is not forthcoming with all information at this time, as he kept stating, “I don’t know, I don’t know”. Discussed plan to continue at most recent dose to avoid benzo w/d given chronic use. Denies and not noticed any sxs of psychosis, mania, depression, anxiety, adamantly denies any active suicidal thoughts nor death wishes, intent or plan.
Differential Diagnoses:
Reflections:
