SOAP Note for Psychotherapy Session- Shelby Colatrela Case

SOAP Note for Psychotherapy Session- Shelby Colatrela Case

Patient Name:  Shelby Colatrela

MRN: XXX

Date of Service:         12-04-2023

Start Time:                10:00               End Time:                  10:22

Billing Code(s): 96127

CC: The client presented with complaints of a drinking problem. She noted that she drinks a lot and that she is unable to quit despite attempting to quit.

HPI: The drinking problem started after she lost her job. She noted that she has been drinking a lot lately and cannot quantify the amount she has been taking. She reports feeling indifferent about drinking and that she no longer feels bad or guilty for not drinking.

S- The drinking problem started when the client lost her job. She is currently in a depressed mood and seems to have lost hope in life and sees no meaning in living; she also feels worthless and that her life is on an irredeemable downward trajectory. She has also had suicidal ideations and reported that she does not care whether her family members will miss her. The client has no known allergies and denied taking any medications.

Crisis Issues: The client reported having suicidal ideation. She is on the verge of committing suicide, citing that she is a hopeless case. She does not reveal details about her plan to end her life. The client, in this case, can be considered as harmful to self.

O- 

Vitals: T 98.4, P 82, R 16, BP 122/78

Heart- R, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

Labs: CBC, electrolytes, and TSH all within normal limits

MSE:

The client is a middle-aged female presenting for counseling. She seems alert and oriented to events, time of day, and place. She is also dressed appropriately for the occasion. She is responsive to the questions being asked and responds to them appropriately. She demonstrates normative speech and affects. Her speech was also rhythmic and properly articulated. She maintained eye contact and calmness throughout the interview. The client seemed to be in a low mood and sometimes hesitated before answering the questions.

Differential Diagnoses:

Depression F32.A

Suicidal ideation R45.851

Substance abuse disorder F10.9 denoting alcohol abuse disorder, unspecified.

Definitive Diagnosis:

Depression, unspecified F32.A with suicidal ideation R45.851. The client in the case presented demonstrated symptoms of depression. Depression is a chronic mental health disorder characterized by feelings of depressed mood, hopelessness, worthlessness, anhedonia, lack of energy, and others. Suicidal ideation or tendencies are often suggestive of severe depression and often warrant prompt initiation of management (Kern et al., 2021). The client in the case presented manifested the symptoms of worthlessness, hopelessness, and depressed mood. She also reported contemplating suicide. These manifestations were suggestive of a depressive disorder.

Plan: 

Pharmacotherapy: The patient will be started on antidepressant medications. Pharmacotherapy maintains effectiveness in the management of depressive disorders. Lieslehto et al. (2023) note that pharmacotherapy is necessary in the presence of suicidal ideations and tendencies as it serves to protect the patient from self-inflicted harm. Selective serotonin reuptake inhibitors are the first-line agents in the management of moderate to severe depression. In this case, the client will be started on 5 mg of fluoxetine, which is administered every 24 hours.

Psychotherapy: The client can also benefit from psychotherapeutic interventions such as cognitive behavioral therapy. This form of talk therapy helps clients cope with difficult life stressors interplaying in their suffering. The client will be scheduled for group therapy.

Education: The client will be educated on the dangers of excessive alcohol consumption. This is in an attempt to prevent her from developing alcohol abuse disorder.

Follow-up: The client is set to remain in inpatient care. She will be reassessed after one week.

Summary

Suicidality is, perhaps, one of the leading forms of self-inflicted safety compromises. It encompasses attempts, ideations, plans, or gestures to commit suicide. In the U.S., suicide is the second leading cause of death among adolescents and younger adults (Becker & Correll, 2020). Suicide ideation and tendencies have long been viewed as a symptomatic presentation. The strongest predictors of suicidal ideations and tendencies are psychiatric disorders such as depression, anxiety, bipolar, psychosis, substance abuse, and personality disorders, among others.

Several indicators in an individual’s health are usually suggestive of suicidality. These include increased verbalization of wanting to die, guilt or shame, and of being a burden to others, feelings of emptiness, hopelessness, worthlessness, or unbearable emotional pain, and behavioral changes such as withdrawal from loved ones and excessive use of substances of abuse (Becker & Correll, 2020).In the case presented, several manifestations of the warning signs of suicide were apparent. The client demonstrated increased verbalizations of shame and wanting to die, behavioral changes, and feelings suggestive of suicide.

As evident in the case, the client noted that she has contemplated ending her life. Additionally, she mentioned that she would care less if her family missed her. These verbalizations are suggestive of suicidal ideations and a warning sign for suicide. Assessment findings on the patients also revealed feelings of worthlessness, hopelessness, loneliness, being overwhelmed, and depressed mood. These feelings are highly suggestive of suicidal thoughts. Behavioral changes were also apparent in the case. She started drinking alcohol and is now a heavy drinker. All these manifestations are warning signs of suicide.

The selected treatment plan encompasses psychotherapy and pharmacotherapy. These modalities were chosen because of their effectiveness in alleviating depressive episodes and cheering the mood of the patients. In this client’s case, these modalities will help in addressing her suicidality and help her have a positive thought process devoid of suicidal thoughts.

References

Becker, M., & Correll, C. U. (2020). Suicidality in childhood and adolescence. Deutsches Ärzteblatt International. https://doi.org/10.3238/arztebl.2020.0261

Kern, D. M., Cepeda, M. S., & Wiegand, F. (2021). Treatment patterns of patients diagnosed with major depressive disorder and suicidal ideation or attempt: A U.S. population-based study utilizing real-world data. BMC Psychiatry, 21(1). https://doi.org/10.1186/s12888-021-03616-1

Lieslehto, J., Tiihonen, J., Lähteenvuo, M., Mittendorfer-Rutz, E., Tanskanen, A., & Taipale, H. (2023). Comparative effectiveness of pharmacotherapies for the risk of attempted or completed suicide among persons with borderline personality disorder. JAMA Network Open, 6(6). https://doi.org/10.1001/

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SOAP Note for Psychotherapy Session- Shelby Colatrela Case

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