Case Soap Note

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

Subjective:

C.C “ I want to kill myself”

HPI: This patient is a 16 year old female with past psychiatric history of major depressive disorder and oppositional defiance disorder who presented voluntarily, by herself, to Crisis with complaints of suicidal ideation with plan to overdose on medications. The patient reports that she and her mother got into a fight, she feels that her mother does not care about her. The patient has been feeling alone, she has been experiencing anhedonia, difficulty sleeping, low energy, decreased appetite, and difficulty concentrating. Patient has previous suicide attempts by overdose and previous admissions, last admission to CAAP 9/28/22. The patient reports occasional cannabis use, last time being within the last 90 days, however, denies further substance use, tobacco, nicotine, or alcohol use. Patient was previously taking Lexapro 10 mg on previous admission, however states that she stopped taking it when she left here. Patient denies history of physical or sexual abuse. Patient's mother, Chantrel McClain (305-915-3816), was spoken to briefly. She reports not knowing that her daughter was here, but stating that she is not surprised because the patient often seeks psychiatric treatment following arguments with her mother. The patient has been reportedly acting normal over the past several weeks and has not been having trouble at school. The patient's mother states that the patient does not have follow up with a psychiatrist nor a psychologist. Patient's mother states that she is not welcome back in her house, and instead she would like to see the patient go live with the patient's father. The patient has not been taking Lexapro 10mg daily which she was discharged on last admission, however, consented for this medication over the phone. Patient has past medical history of ovarian cyst and asthma. " On interview, patient states that she got into a fight with her mother and afterwards, started to have active and passive suicidal ideations of wanting to overdose and wishing she was never born. Patient reports feeling that her mother pays more attention to her sister and to her mother's fiance and blames everything on her. Patient would not disclose what specifically caused the argument. Also reported feeling depressed these past couple of weeks and endorsed associated anhedonia, poor sleep/low energy, poor appetite, and altered concentration. States that she feels she is always being blamed by her mother. Reports issues with anxiety and identifies that there is a stressor that potentially contributed to her current symptomatology but patient refused to elaborate. Patient states that she is not currently on medication or established in outpatient therapy. Otherwise, denies any history of trauma or associated PTSD symptoms. Denies any history of obsessions or compulsions. Denies any history of manic/hypomanic episodes. Denies any auditory/visual hallucinations or delusional beliefs and is not observed to be responding to internal stimuli. Per collateral, mother states that patient had been staying at her godparent's house after school more than she is supposed to and not returning home and this is what mother confronting her about yesterday. She states that patient later texted her that she wanted to kill herself. States that she has noticed patient crying a lot more and attributed this to patient's biological father not sending her any money recently. She is not aware of any other stressors for patient. She confirms that patient is not established in outpatient therapy and is not currently on medication. Discussed clinical status, risk status, and treatment plan. Guardian expressed verbal understanding and agreement with current plan. Based on symptoms and behaviors described above: - There is evidence of symptoms and behavior reflecting impairment, and continued treatment in an inpatient psychiatric setting is warranted at this time - No less restrictive alternative is presently available - Patient continues to meet criteria for inpatient admission to BH Unit Substance Use: Alcohol: denies Nicotine: denies Drug Use: endorses occasional use of marijuana Detox/Rehab: denies Exposure to Trauma: Physical: denies Sexual: denies Neglect: denies Medical History: Past medical history: asthma and ovarian cyst Past surgical history: denies Seizures: denies Head injury (LOC, TBI, etc): denies Current nonpsychiatric medications: denies Psychiatric History/Psychological Evaluation: Inpatient treatment: a couple in the past Outpatient treatment: denies Suicide history: aborted suicide attempts Nonsuicidal self injurious behavior: denies Prior medications: fluoxetine and escitalopram Current psychiatric medications: denies Developmental History: Birth History: uncomplicated, vaginal delivery, full term Developmental Milestones: Walked at: on time Talked at: on time Toilet trained: on time Emotional development: within normal limits Social development: within normal limits Family Medical/Psychiatric History: Mental illness: denies Substance abuse: denies Suicide: denies Medical: mother has hypertension Social History: Born: Miami Raised by: mother Siblings: 5 siblings (3 brothers, 2 sisters) Lives with: mother, sister, and mother's fiance Relationships: Sexually active: denies Educational History: Grade: 11th grade School: Lindsey Hopkins Technical College Performance: good grades Suspensions/Expulsions: expelled from previous high school Bullying: denies Legal History: Legal guardian: Mother History of arrest: denies Mental Status Exam: Appearance/Behavior: appears stated age, fair grooming/hygiene, dressed in hospital gown, somewhat guarded and moderately cooperative Eye Contact: fair Motor Activity: no PMA/PMR, AIMS absent Speech: non-spontaneous; normal volume, rate, and prosody Mood: "depressed"; observed to be dysphoric Affect: constricted, congruent with stated mood Thought Process: linear, organized Thought Content: no preoccupations, no obsessions or compulsions elicited, no phobias elicited, no delusions elicited Perceptual Disturbances: denies AVTOG hallucinations, does not appear RTIS Suicidal Ideation/Intent/Plans: endorses passive suicidal ideations Homicidal Ideation/Intent/Plans: denies Insight/Judgment: poor/poor Orientation: alert and oriented to self and situation Attention/Concentration: fair/fair Fund of knowledge: average Memory: not formally evaluated, appears grossly intact Vital Signs: Height: 159.2 cm Weight: 51.9 kg Temperature Oral: 36.9 DegC Peripheral Pulse Rate: 69 bpm Respiratory Rate: 20 br/min Systolic Blood Pressure: 108 mmHg Diastolic Blood Pressure: 50 mmHg Pain Present: No actual or suspected pain Review of Systems: Constitutional: does not complain of fever, chills, or fatigue HEENT: does not complain of vision changes, congestion, or sore throat Skin: does not complain of rash or itching Cardiac: does not complain of chest pain or palpitation Respiratory: does not complain of cough or shortness of breath Gastrointestinal: does not complain of abdominal pain, nausea, vomiting or diarrhea. Genitourinary: does not complain of dysuria Neurological: does not complain of dizziness, headaches, or weakness Musculoskeletal: does not complain of muscle pain, joint pain, or stiffness Hematologic: does not complain of easy bleeding or bruising Scales none administered at this time Medical Decision Making:

Differential Diagnoses Unspecified mood (affective) disorder F39 Oppositional defiant disorder F91.3 Impulse control disorder F63.9 Target Symptoms: suicidal behavior/ideation depression non-adherent behaviors temper outbursts Treatment Recommendations/Plan: 1) Occupational/Recreational/Activity Therapy: will participate 2) School: will attend 3) Scales: none at this time 4) Information: previous records, school information 5) Studies to be ordered: none 6) Consults: none 7) Precautions: level 1 8) Individual sessions: psychoeducation, safety, coping skills 9) Family sessions: psychoeducation, safety, length of stay 10) Suicide risk: low in the unit, no 1:1 sitter required at this time 11) Medications: - Starting escitalopram 5 mg daily for mood/anxiety PRNs are in place 12) Aftercare planning: medication management, individual therapy 13) Estimated length of stay: guarded

Make sure all these are completed:

Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS

Discuss Objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

Discuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

Discuss treatment Plan:• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health.

This criterion is linked to a Learning OutcomeReflect on this case. Discuss what you learned and what you might do differently.