SOAP Note: Subjective: 50-year-old female patient presents with complaints of extreme tiredness, agitation, chest pains, and worries about a number of health problems. She has a history of GAD, depression, and a past overdose following a relationship break-up. She reports feeling nervous and easily getting “in a state” when dealing with everyday stresses and has been drinking wine in the evenings to calm herself down. More recently, she has had thoughts of self-harm and describes a plan to end her life.
Objective: Vital signs include BP of 122/68, HR of 74, R of 18, T of 97, and O2 of 99%. Pain score is 2 on a 0-10 scale. Weight is 147 pounds and height is 66 inches.
Assessment: The patient is at high risk for self-harm and suicidal ideation. Further assessment and treatment is necessary to ensure her safety.
Plan:
- Safety plan: Develop a safety plan with the patient and her family, including identifying warning signs, removing access to means of self-harm, and developing a system for checking in and seeking help when necessary.
- Education: Educate the patient and her family about the importance of maintaining a safe environment, including reducing access to drugs and alcohol, and identifying coping strategies to help manage suicidal thoughts.
- Follow-up: Schedule more frequent follow-up appointments and consider referral to a specialist for further evaluation and treatment.
- Psychotherapy: Recommend psychotherapy, such as Cognitive Behavioral Therapy (CBT), which has been shown to be effective in treating depression, anxiety, and suicidal ideation.
- Monitoring: Consider admission for monitoring and monitoring of suicidal thoughts and behavior.
Overall, the priority is to ensure the patient’s safety and provide her with the support and resources she needs to manage her symptoms and improve her mental health. Collaboration between the healthcare provider, patient, and her family is essential for a successful outcome.
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