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Mallory Miner

SOAP Note #1
Identification:
JK: 21 y.o
Caucasian Female
BYU-Idaho Student Health Insurance
Subjective:
CC: First time Mental Health Referral from BYUI Counseling Center
HPI: JK was dx with depression in 2015 in Pocatello. Pt was previously on Citalopram,
but she felt “flat” on it and stopped taking it. Pt saw a therapist in 2015 and was
treated for anxiety with no medication just weekly counseling. Pt moved away to
“take a break and live with my aunt in North Carolina” where she stopped taking her
medication and stopped seeing a counselor as well. Pt states she is currently
experiencing a loss in interest or enjoyment of normal daily activities. Pt also states
she experiences persistent sad, anxious, and hopeless moods as well as
nervousness and irritability. States her sleep is “OK.” But she has experienced
overtiredness and decreased energy in the past. States she experienced significant
weight loss in the past, about 20 pounds, over the past year. Denies difficulty
concentrating, remembering, and or making decisions. Denies current suicidal
thoughts. States she has thought about suicide in the past. Denies taking any other
medications at this time. Pt states her homework will sometimes cause anxiety.
Med Hx:
Dx depression in 2015
ADHD- attentive in 2009
*was on Adderall but has not taken for 7 years
Past Surgical History: None.

Family History:
Mom: HTN, Anxiety, Depression, ADHD, Anemia
Dad: Anxiety, Depression, ADHD
Siblings: 3 siblings, 2 of which are adopted. All healthy. Pt is oldest.

Hospitalizations:
None.
Allergies:
Penicillin
Medication:
None.
Immunizations: Up to date. Last influenza vaccine 09/2016.
Social: Pt is a single college student attending BYU-Idaho. She lives in an on
campus apartment that she shares with 3 other girls. Her major is Horticulture and
she enjoys playing the cello. She does not have a car at college and walks to get to
campus, the store, etc. She denies any pets at college. She denies ever being
sexually active. Denies any alcohol, drug, or tobacco use. Denies any second hand
smoke or toxin exposure.
ROS:
Generalized: Pt reports she feels depressed. Denies fevers, chills, sweats.
Neurologic: Denies seizures, syncope, tremors, vertigo.
Psychiatric: See HPI, depression, anxiety. Denies memory loss, mental disturbance,
suicidal ideation, hallucinations, paranoia.
Cardiovascular: Blood pressure well controlled, denies chest pain or palpitations.
Respiratory: Denies shortness of breath, dyspnea or cough.
GI: Denies nausea, vomiting.
Musculoskeletal: Denies numbness or tingling. Denies back pain, joint pain, muscle
cramps.
LMP: Started menarche age 13. Regular schedule, moderate flow with mild
cramping.
Endocrine: Denies cold intolerance, heat intolerance.
Heme/Lymphatic: Denies abnormal bruising, bleeding.
Allergic/Immunologic: Pt states she is allergic to Penicillin.
Objective:
Vital Signs: Ht:63in, Wt.: 164bs, T: 98F, HR: 97, RR: 16, SPO2: 95% RA, BP: 110/80,
Pain: 0/10
Generalized: Pleasant but concerned. Alert and oriented in no acute distress. Steady
gait.
Neurological: A&Ox4. Face is symmetrical, jaw muscles intact. Cranial nerves II-XII
grossly intact.
Mental Status Exam: Mood and affect: pleasant.
Cardiovascular: Tachycardia. RRR without murmurs, S1S2 present, pulses 2+. No
edema, thrills or bruits.
Respiratory: RRR. No abnormal breath sounds noted. No dyspnea or accessory
muscle use.
GI: flat soft symmetric appearance, + BS x 4 quadrants.
Musculoskeletal: Musculoskeletal: +5/5 strength bilateral UE and LE. Full AROM.

Assessment:
1. Anxiety/depression (ICD-300.4) (ICD10-F41.8)
2. Screening for thyroid disorder (ICD-V77.0) (ICD10-Z13.29)
3. Screening for iron deficiency anemia (ICD-V78.0) (ICD10-Z13.0)

Differential diagnosis:
Depression:
-Generalized anxiety disorder
-Obsessive-compulsive disorder
-Panic disorder
-Phobic disorders
-Posttraumatic stress disorder
Thyroid:
-Anemia
-Autoimmune Thyroid Disease and Pregnancy
-Euthyroid Sick Syndrome
-Goiter
-Myxedema Coma or Crisis
-Riedel Thyroiditis
-Subacute (granulomatous, De Quervain) Thyroiditis
-Thyroid Lymphoma
-Thyroiditis, Subacute
-Thyroxine-Binding Globulin Deficiency
-Iodine Deficiency
Anemia:
-Alpha Thalassemia
-Aplastic Anemia
-Beta Thalassemia
-Hemolytic Anemia
-Iron Deficiency Anemia
-Low LDL Cholesterol (Hypobetalipoproteinemia)
-Megaloblastic Anemia
-Myelophthisic Anemia
-Pernicious Anemia
-Sickle Cell Anemia
-Spur Cell Anemia
Plan:
Pt was sent to lab because she has never had a blood test through all of her
appointments for depression over the years. Discussed with pt that we are looking
for anemia, thyroid, and other pathological causes that the depression may be
masking.
Pt was also given an Rx for Zoloft 50mg #30. Pt was instructed to make a follow up
appointment in 3-4 weeks to see how she is tolerating new medication. Also
educated pt that at some future point her ADHD may also need to be revisited. Also
recommended that she should stop by the BYUI counseling center on her way out to
schedule an appointment. Pt verbalized understanding and had no further questions
at this time.
1. Anxiety/Depression Education:
Encouraged to continue meeting with student counseling center
Encouraged to continue with cardiovascular exercise 3-5 times a week and
educated on the benefits to mental health.
Discussed medication
Encouraged self-time daily to decrease stress.
Therapeutic:
ZOLOFT 50 MG TABS (SERTRALINE HCL) 1/2 tab po qday x 5 days then increase to 1
tab po qday #30[Tablet]
2. Screening for thyroid disorder
-Tests: (1) Vitamin D (491)
Order Note: Values between 10 ng/mL and 30 ng/mL indicate insufficiency.
Vitamin D, 25-Hydroxy
[L] 14.6 ng/mL 30.0-100.0
-Tests: (1) TSH w/reflexFreeT4 (1029)
TSH 2.63 IU/mL 0.30-3.00
Vitamin D, 25-Hydroxy, 14.6 ng/mL, (F)
3. Screening for iron deficiency anemia
-CBC: WBC: 6.80; RBC: 5.61; HgB: 10.20; Hct:33.3; Plt: 247
-Tests: (1) Anemia Microcytic Panel (Iron Def) (4008)
%Saturation (5.1) [L] 3.1 % 20.0-55.0
Direct TIBC (5.1) 455 ug/dL 265-497
Ferritin [L] 3.1 ng/mL 15.0-137.0
Iron (5.1) [L] 14 ug/dL 37-170
%Saturation (5.1), 3.1 %, (F)
Direct TIBC (5.1), 455 ug/dL, (F)
Ferritin, 3.1 ng/mL, (F)
Iron (5.1), 14 ug/dL, (F)

Current Orders List:
Ofc Vst, New Level III
TSH w/Reflex FT4
Anemia-Microcytic Panel
CBC
New Medications List:
ZOLOFT 50 MG TABS (SERTRALINE HCL) 1/2 tab po qday x 5 days then increase to 1
tab po qday #30[Tablet]
Mallory Miner, DNP Student

Evidence-Based Practice: When evaluating research, the hierarchy of evidence is
used to find the research’s strengths/weakness’s on the evidence scale. The article I
chose this week, is Association between depression and anemia in otherwise
healthy adults. I chose this because I was curious to see the connection between
depression and anemia.

The authors state how it still remains a debate as to whether anemia is associated
with depression, independently of physical health factors. Their research was a
largescale cross-sectional study examining this association in adults free of chronic
disease and medication from the general population (Vulser, Wiernik, Hoertel,
Thomas, Pannier, Czernichow & ... Lemogne, 2016).
A largescale cross- sectional study is level IV in the hierarchy of evidence, which is
made up of well-designed case-control and cohort studies. This is located in the
middle of the evidence hierarchy, and is good research. Even though not the
strongest, it should still be used when looking for evidence and included due to its
relevance of the topic.
In this study Hemoglobin levels were measured among 44,173 healthy participants.
Depression was measured with the Questionnaire of Depression 2nd version,
Abridged. Furthermore, logistic regression analyses were performed to examine the
association between anemia and depression, while adjusting for a wide range of
sociodemographic characteristics and health-related factors (i.e., sex, age, living
status, education level, occupational status, alcohol intake, smoking status, physical
activity, and body mass index (Vulser, Wiernik, Hoertel, Thomas, Pannier,
Czernichow & ... Lemogne, 2016).
Although no conclusion could be drawn about causality, these findings suggest that
patients with depression should be screened for anemia and that patients with
anemia should be screened for depression. The results showed that depressed
participants were significantly more likely to have anemia compared to non-
depressed participants, even after adjustment for sociodemographic and health-
related variables. The authors conclude that further studies are needed to assess
the longitudinal relationship between both conditions and determine the
mechanisms underlying this association (Vulser, Wiernik, Hoertel, Thomas, Pannier,
Czernichow & ... Lemogne, 2016).

Reflection: From my learning goals feedback, Dr. Arvidson asked what areas I see as
my weakest, as well as what diagnoses I wanted to focus on from these areas. I
would have to say anemia is one of these areas, especially iron deficiency anemia. I
am comfortable with treating depression because at BYU-Idaho in order to be seen
the student must have a referral from the Counseling Center, which this patient did,
and then usually an antidepressant is started and the patient follows up with both
the counseling and health centers to see whether or not the treatment is helping.
However, with iron deficiency anemia, it is definitely something I have to think
about as far as the treatment plan is concerned. One treatment option is to have
the patient take oral iron supplementation. When I was talking with my preceptor
she said many times she will just refer to a hematologist because the BYU-Idaho
student health center just doesn’t have the resources that are needed. I also
remember walking out of the room thinking there was more to the story than just
the depression. The lab tests revealed that her iron and ferritin were low. She was
also vitamin D deficient. The study also helped me feel good about the education
and plan for the patient because we were able to address both depression and
anemia. Looking back on this patient, I learned the importance of checking all the
potential causes and pairing them, for example depression and anemia, to check for
pathological causes that the depression may be masking. This exam also taught me
the importance of inter-professional teamwork/collaboration with the counseling
center because in this case both were needed.

Reference
Vulser, H., Wiernik, E., Hoertel, N., Thomas, F., Pannier, B., Czernichow, S., & ...
Lemogne, C. (2016). Association between depression and anemia in otherwise
healthy adults. Acta Psychiatrica Scandinavica, 134(2), 150-160.
doi:10.1111/acps.12595