SOAP Note: 48-year-old Hispanic Female with Depression with Psychotic Features

ANSWER

DEPRESSION WITH PSYCHOTIC FEATURES

Running Head: DEPRESSION WITH PSYCHOTIC FEATURES

IDENTIFYING DATA

MM is a 48-year-old divorced Hispanic female who was brought to the clinic by her son after being discharged two days ago from a crisis unit after an episode of psychosis.

CHIEF COMPLAINT

“Feeling that the FBI is following me, and my parents want to poison me.”

FAMILY HISTORY

The patient reports that her 67-year-old mother was born in Cuba and emigrated to the United States a year ago with her father. Her mother completed high school and is not currently working; she does not speak English and relies solely on the patient’s income for support. The mother does have a history of hypertension and rheumatoid arthritis and also reports a history of depression, which the patient called “un Estado de nervios.” The patient’s 69-year-old father completed high school and worked as a mechanic in his native country, and he is not currently working because he is waiting for his work permit. He has a medical history of hypertension, obesity, and benign prostate hypertrophy. The patient’s father does not have an account of substance or mental health problems. However, he smokes a pack of cigarettes daily. A patient has one sibling, a younger sister, who is still living in Cuba; her sister is healthy and has no history of substance abuse or mental health problems. The patient also reports that on her mother’s side, two of her aunts suffered from postpartum depression, as well as one of her cousins. She also states that two of her uncles were alcoholics. On her father’s side, the patient reports a history of substance abuse by two of her paternal uncles.

PERSONAL HISTORY

The patient reports having no birth issues; she was born through standard delivery, full term, and with no complications. The patient also reports completing all the milestones and doing well in school. She states that the only issue growing up was her father’s ten-year incarceration as a political prisoner, which was traumatic, and she became very fearful after that. Since then, she has never been able to speak her mind. She states,” I rather not say anything, even when I know it is not right.”

MEDICAL HISTORY

The patient does not have health insurance, and the last time she saw a physician was when she did a physical for her employment. Her immunizations are up to date, and she has no food or medication allergy. She has a history of endometriosis, which she states “it resolved in her mid-thirties.” She also injured her back a year ago and said that she received injections, but she does not know the name of the medication. She denies any other problems, except for occasional cold and sore throat. Which is treated with over-the-counter medications. Otherwise, she has never been hospitalized, except during childbirth, which was standard delivery. Currently, the patient is taking multivitamins and sleepy-time tea. She has not had mammography or PAP smear in the last five years. Her laboratory results show microcity anemia and slightly elevated LDL. Laboratory results on admission to her hospitalization, including thyroid-stimulating hormone and thyroxine, were all within reasonable limits. Her blood pressure and weight are within normal limits.

SOCIAL HISTORY

The patient shares a two-bedroom apartment with her mother and father. She reports being married for two years to the father of her son. Since then, she has not had any romantic or sexual relationships because her life was dedicated to her son. She has no friends currently, only some coworkers whom she frequents. The patient states, “I work from 7 AM to 11 PM, I have to support my family, I have no time for friends”, She denies having any hobbies or interests. She enjoys watching Spanish television. She does not smoke, drink alcohol, or consume any illegal substances. The patient denies any history of legal problems. The patient’s only son is a 19-year-old college student accompanying the patient to this evaluation. She reports having a great relationship with her son and that his living at school has been very hard on her.

OCCUPATIONAL HISTORY

The patient is a high school graduate with no military service history and a nursing assistant certificate. She has two jobs and states,” the situations are very demanding; I have two spend most of the time bathing patients and feeding them.” I have been working steadily for the past two years without a vacation or a weekend off”. The patient reports that her recent hospitalization reduced her work hours to 40 weekly.

PAST PSYCHIATRIC HISTORY

The patient denies any outpatient or psychiatric hospitalization history before the admission described above. She was discharged two days ago from the crisis unit. She started on Risperdal 2 mg. At bedtime, Trazodone 100 mg PO HS and citalopram 20 mg. In the AM. The patient reports having an episode of depression right after the birth of her son. She denies having any treatment or follows up for the incident. She states,” after giving birth to my son, I felt sad, tired and had weird thoughts; for months I did not feel any happiness. It lasted about two years, and then it went away.” No history of suicidal or assaultive behavior.

HISTORY Of PRESENT ILLNESS

The patient reports feeling nervous since her son left for college six months ago. In the last three months, her sleep has deteriorated to the point that she was only sleeping for two or three hours at night. Two weeks ago, after working the night shift, she thought people were following her; she saw lights everywhere and became very frightened. She also reports at that time, starting hearing voices telling her that the FBI was after her. The patient also lost about 10 pounds because she believed her parents wanted to poison her. She states,” I was so scared that I decided to drive my car against a tree.” The patient reports that the symptoms were so frightening that she stopped her car in the middle of the road and asked a policeman for help. Son says that his mother has been experiencing a lack of sleep and mood swings since moving to the United States about five years ago. Son reports that his mother works all the time and sometimes becomes irritable and distant. PHQ-9 was administered, and her score was 25, which indicates “severe depression.”

IMPRESSION

48-year-old Hispanic female with a family history of depression and a personal account of untreated postpartum depression. Who now presents with auditory hallucinations, paranoid thinking, sleep disturbances, and loss of interest in daily activities that were aggravated by their son moving to college and working multiple jobs for about 16 hours a day. The patient is stressed due to her economic situation; she feels responsible for her parents and son. Patient presentation is consistent with a recurrent Major depression disorder with psychotic features. The treatment will be focused on helping her and her family to decrease the patient’s stressors, such as working long hours and loneliness. Psychotic symptoms are associated with numerous social factors, such as migration and urban upbringing. Isolation is related to positive traits and depression. Symptoms of paranoia are precisely the impression that other people are giving odd looks and that other people are not what they seem to be related to loneliness (Jaya, Hillmann, Reininger, Gollwitzer & Lincoln, 2017). Psychotic symptoms of depression are often associated with poor social functioning (Sönmez et al., 2016). The patient does not have a social network or participate in leisure activities.

Furthermore, the patient needs to monitor some of her symptoms further correlated with bipolar disorder mixed type. Jääskeläinen et al. (2018) systematic review found that psychotic depression’s first episode is a marker of later bipolar disorder. Sleep is another issue that needs to be addressed since sleep is associated with psychotic symptoms and worsening depression (Koyanagi & Stickley, 2015).

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Gabbay, V., Johnson, A. R., Alonso, C. M., Evans, L. K., Babb, J. S., & Klein, R. G. (2015). Anhedonia, but not irritability, is associated with illness severity outcomes in adolescent major depression. Journal of child and adolescent psychopharmacology, 25(3), 194-200.

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