- Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. Please Note:
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
- *** See case study and template attached
Include under treatment and plan your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
History
You are asked to see a 69-year-old woman who complains of feeling constantly tired and not enjoying anything including her grandchildren. She sleeps for 8 hours or more but still never feels rested. She finds herself getting increasingly irritable and snappy with her 37-year-old daughter who is now living with her following the breakdown of her marriage. The daughter has two children ages 10 and 12 for whom the patient is having to provide care because her daughter is unable to manage this. The patient is finding the demands of her daughter, grandchildren and husband more and more difficult to cope with. She often forgets what needs to be done. Further questioning reveals that her daughter has agoraphobia and depression. She has no previous history of mental health problems. She has hypertension which is well controlled.
Mental state examination
The woman looks tired and much older than her 69 years. She is obese and her dress is rather erratic. She has lots of layers of clothing and seems unaware that she has come in her slippers. She looks tired. Her speech is slow, flat and monosyllabic. She states she feels okay but she looks and sounds low. She does not have any active suicidal ideation but does question whether life is worth living. She feels hopeless about the circumstances she finds herself in. She has no hallucinations or formal thought disorder.
Subjective: The patient is a 69-year-old woman presenting with constant fatigue, anhedonia, irritability, and increased stress due to caregiving responsibilities for her grandchildren alongside managing her daughter’s agoraphobia and depression. She reports sleeping for adequate hours but never feeling rested. She expresses feelings of hopelessness and questions the value of life. No active suicidal ideation is reported.
Objective:
- Appearance: The patient appears tired and older than her age, obese, and dressed erratically with multiple layers of clothing and inappropriate footwear (slippers).
- Speech: Slow, flat, and monosyllabic.
- Mood/Affect: Appears low, with expressions of hopelessness. No active suicidal ideation noted.
- Cognitive Function: Reports forgetfulness and difficulty coping with increased demands.
Assessment: Primary Diagnosis: Major Depressive Disorder (MDD) with features of fatigue, anhedonia, hopelessness, and cognitive impairment.
Plan:
Treatment:
- Pharmacotherapy: Initiate treatment with an FDA-approved antidepressant, considering the patient’s comorbid condition of hypertension. Sertraline, a selective serotonin reuptake inhibitor (SSRI), at a low starting dose due to medical history and close monitoring for potential interactions.
- Rationale: SSRIs have shown efficacy in treating depression in older adults and have a favorable side effect profile.
- Alternative: In case of intolerance or inadequate response, consider other antidepressants like bupropion or mirtazapine, balancing efficacy and side effect profiles.
- Supportive Research: Referencing studies on SSRIs in elderly populations and their efficacy in managing depression while considering comorbidities.
- Psychotherapy: Recommend cognitive-behavioral therapy (CBT) or supportive therapy to address coping strategies, caregiver stress, and negative thought patterns.
- Rationale: Psychotherapy, particularly CBT, has demonstrated effectiveness in treating depression and enhancing coping skills.
- Supportive Research: Citing studies showcasing the efficacy of psychotherapy in elderly populations with depression and caregiver stress.
Follow-up Plan:
- Schedule a follow-up in two weeks to assess medication tolerance, side effects, and initial treatment response.
- Regular follow-ups every 4-6 weeks to monitor progress, adjust dosage, or consider additional interventions if necessary.
Referrals: Refer the patient to a licensed clinical psychologist or therapist specializing in geriatric mental health and caregiver support to provide ongoing therapy and support.
This SOAP note outlines a treatment plan encompassing pharmacotherapy, psychotherapy, and follow-up protocols tailored to the patient’s needs while integrating scholarly research to support clinical decisions.