Angela Cortez SOAP NOTE Assignment

Angela Cortez SOAP NOTE Assignment

Angela Cortez SOAP NOTE Assignment

NSG 502

Angela Cortez I-Human

Assessment: Angela is a 17-year-old female who presents with increased fatigue over the past two months. Angela has had recent weight gain. She also presents with increased irritability and tearfulness. Angela describes always being tired and loss of interest in every-day activities. She is obese with mild acne, states she’s feels unhappy with the way she looks. Currently Angela denies any suicidal ideation.

Upon completion of assessment, it appears that Angela is suffering from adolescent depression disorder. However, it is important to complete lab work to rule out any other cause of her symptoms. A complete blood count, thyroid studies and heterophile antibody test has been completed to determine if some pathological reason is contributing to Angela’s fatigue and lack of energy. The CBC has come back within normal limits, ruling out acute infection as a cause of Angela’s symptoms. The thyroid studies are also in normal limits, ruling out thyroid disorder as a cause of symptoms. Due to Angela’s age and symptoms a heterophile antibody test is appropriate to rule out mononucleosis as a cause of symptoms. This test came back negative, ruling out mononucleosis. A urine cortisol test was completed to rule out pathological causes of Angela’s symptoms. This test was within normal limits.

Due to Angela’s personality changes and irritability, a urine drug screen is appropriate. This test was negative for all drugs. Angela admitted to being sexually active with her former boyfriend, so a pregnancy test is appropriate. The pregnancy test was negative.

Angela is mildly obese and has a family history of diabetes mellitus. A fasting blood sugar and hemoglobin A1C are appropriate to be checked. Angela’s blood sugar and hemoglobin A1C are within normal limits.

After ruling out pathological reasons for Angela’s symptoms, the healthcare provider can confidently begin treating for adolescent depression disorder. Angela will need a combination of both pharmacotherapy and psychotherapy.

Angela should be started on a selective serotonin re-uptake inhibitor (SSRI) (NIMH, 2018). SSRI’s are the first line antidepressant (NIMH, 2018). SSRI’s are used because they have very little side effects and are less likely to cause overdose in patients (NIMH, 2018). Fluoxetine, which is an SSRI, has been shown to be very effective in children and adolescents (NIMH, 2018).

Psychotherapy should be used in conjunction with pharmacotherapy. Angela should be contracted for safety (NIMH, 2018). A contract for safety is a tool used by the healthcare provider and the patient that the patient signs, stating they will not harm themselves or commit suicide (NIMH, 2018). The combination of pharmacotherapy and psychotherapy has been shown to be the most effective treatment for adolescents with depression (NIMH, 2018).

References

National Institute of Mental Health. (2018). NIMH: Antidepressant Medications for Children and Adolescents: Information for Parents and Caregivers. Retrieved from

 

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