SOAP Note Questions for 17-Year-Old Sertraline Overdose Patient
Sertraline overdose in adolescents requires immediate assessment for serotonin syndrome, cardiac complications, and mental health evaluation, with activated charcoal already appropriately administered within the critical 1-2 hour window.
History Questions
Overdose Details
- Exact time of ingestion to establish timeline
- Confirmation of exact dose (18-20 tablets of 25mg = 450-500mg total)
- Was this a suicide attempt or accidental ingestion?
- Any prior suicide attempts or self-harm behaviors?
- Any other medications or substances ingested concurrently (especially other serotonergic drugs, benzodiazepines, alcohol)
Psychiatric History
- Duration of sertraline treatment and prescribed dosage
- Reason for sertraline prescription (depression, anxiety, OCD?)
- Compliance with medication regimen
- Recent changes in medication or dosage
- Current psychiatric symptoms (depression, anxiety, suicidal ideation)
- Previous psychiatric hospitalizations
- Family history of mental health disorders or suicide attempts
Physical Examination Focus
Vital Signs
- Temperature (hyperthermia may indicate serotonin syndrome) 1
- Blood pressure and heart rate (monitor for hypertension and tachycardia)
- Respiratory rate (assess for respiratory depression)
Neurological Assessment
- Mental status (confusion, agitation, hallucinations)
- Neuromuscular abnormalities (tremor, hyperreflexia, myoclonus, rigidity) 1, 2
- Pupillary response (mydriasis)
- Coordination and gait
Gastrointestinal Assessment
- Nausea, vomiting, abdominal pain 3
- Bowel sounds
Skin Assessment
- Diaphoresis, flushing 1
- Temperature, color
Laboratory and Diagnostic Tests
Immediate Tests
- Complete blood count
- Basic metabolic panel (electrolytes, renal function)
- Liver function tests
- Creatine kinase (to assess for rhabdomyolysis) 1, 2
- Coagulation studies
- Urine toxicology screen
- Serum sertraline levels (if available)
- ECG (to rule out QT prolongation or arrhythmias)
Additional Tests
- Arterial blood gas (if respiratory distress)
- Chest X-ray (if respiratory symptoms)
Treatment Plan Questions
Immediate Management
- Has the patient's airway been secured?
- Has fluid resuscitation been initiated?
- Is continuous cardiac monitoring in place?
- Has the poison control center been contacted?
Pharmacological Interventions
- Is benzodiazepine therapy needed for agitation or seizures? 1
- Is cyproheptadine indicated for possible serotonin syndrome? 1
- Are there contraindications to flumazenil if benzodiazepines were co-ingested? 4
Disposition Planning
- What is the plan for psychiatric evaluation once medically stable?
- Is transfer to PICU indicated based on clinical presentation? 1
- What is the estimated duration of observation required?
Monitoring Questions
Short-term Monitoring
- What vital sign parameters require immediate intervention?
- What neurological changes would indicate worsening condition?
- What is the monitoring schedule for laboratory values?
Long-term Planning
- What follow-up psychiatric care is needed?
- Is medication adjustment necessary upon discharge?
- What safety planning has been discussed with the family?
- What resources have been provided for suicide prevention?
Key Considerations
- Serotonin syndrome risk: Monitor closely for the triad of mental status changes, autonomic instability, and neuromuscular abnormalities 1
- Cardiac monitoring: Although sertraline is generally safer than tricyclic antidepressants in overdose, continuous cardiac monitoring is still indicated 3, 5
- Rhabdomyolysis risk: Monitor CK levels due to potential for muscle rigidity and hyperthermia 1
- Psychiatric evaluation: Essential once medically stable to assess suicide risk and need for inpatient psychiatric treatment
- Family education: Provide information about medication safety, suicide prevention, and monitoring
Most sertraline overdoses have relatively minor symptoms of short duration 3, but this patient's significant ingestion (450-500mg) requires close monitoring for at least 24 hours, particularly for development of serotonin syndrome, which can be life-threatening and may require ICU admission 1.