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Week two: Comprehensive Focused SOAP Psychiatric Evaluation

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College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Nursing

March 19, 2021

Subjective

Chief Complaint (CC): Client with no current complaint, came in to the clinic for her follow-up appointment regarding her ADHD medication management, endorses medication compliant and no side effects reported.

HPI: JM is a 16 year-old Caucasian female, who came in for her routine follow-up visit for medication management for ADHD and DMDD. JM was initially referred after her last inpatient psychiatric hospitalization and has been complaint with her treatment plan and medication management. She reports effectiveness with medication and has experienced less irritability, anger, mood swings, and anxiety. JM was prescribed Intuniv 1mg PO every morning, to control attention deficit hyperactivity disorder, Focalin XR 5Mg PO every morning for attention deficit hyperactivity disorder, and Seroquel 100mg at bedtime for mood. JM reports she has been doing well in school, keeping good grades, sleeping well at night and appetite is good.

Past Psychiatric History: Client was diagnosed at young age with Disruptive mood dysregulation disorder (causing anger, mood swings, temper, irritability, and anxiety), Attention deficit hyperactivity disorder (causing the patient to lose interest in any physical activity that requires to be done for long), and cannabis use, when she break up with the boyfriend, which traumatized her, and she started using cannabis. She has been admitted several in the hospital for a mood disorder and attention disorders.

Substance Current Use: She endorses illicit use of Cannabis Sativa, denies abuse of prescribed drugs, alcohol and poly substance abuse.

Medical History: The client started taking cannabis at a young age. She became a regular user of cannabis. She does not use any other drug apart from cannabis. At one time, the client could not do without cannabis, but she reports that she has been going for days without taking the drug of late. She tried detoxing from cannabis, but she experienced nausea, tremor, and vomiting (Goldstein-Piekarski et al., 2016). She reports that her ADHD is well managed with her prescribed medications, her medical conditions are improving. She has no signs of heart problems. She does not report chest pains; the family has no history of cardiac problems. The client says that she believes that the medication is becoming successful and reports that her mood is back to normal.

· Current Medications: The patient is taking Intuniv 1mg to control attention deficit hyperactivity disorder, Focalin XR 5Mg Po every morning for attention deficit hyperactivity disorder, and Seroquel 100mg qhs for mood (Bruno et al., 2019). All these medications aim to make her feel better and enhance her condition.

· Allergies: the client denies any history of allergy to either food or perfumes.

· Reproductive Hx: The client is a 16-year-old virgin lady with a regular menstrual cycle—no history of contraceptives.

ROS:

· GENERAL: the client is not showing any sign of brain damage. She speaks intelligently, showing she has no challenges with her IQ.

· HEENT: The client has red eyes, but she does not report any blood pressure problems. Her ears were normal; her throat was normal too. Her oral cavity is normal. Her hearing and vision conditions are intact. She has no history of vision problems. She does not wear eyeglasses or contact lenses. The ears are in good condition. The client took an eye examination three months ago. The smell is normal, and the buccal mucosa is intact. The patient had a dental exam nine months ago with no conditions such as bleeding gums. His throat is in a condition with no history of sore throat or throat cancer.

· SKIN: the client reports acne on her skin.

· CARDIOVASCULAR: The patient does not report any chest pains, not heart attacks. The family history does not have any history of heart problems.

· RESPIRATORY: The client reports shortness of breathing, especially after doing physical exercises.

· GASTROINTESTINAL: Client denies constipation, nausea, vomiting, reports normal abdominal cramps during her menstrual circles.

· GENITOURINARY: the patient does not report any form of a urinal or genital disorder other than UTI, which was treated, and she fully recovered.

· NEUROLOGICAL: The patient shows a good reflex.

· MUSCULOSKELETAL: The patient did not report any muscle or joint pains. Her movement is normal. There are no swellings and redness of the joints.

· HEMATOLOGIC: HCT and HB count are normal

· LYMPHATICS: Palpation results shows that the lymph nodes are okay.

· ENDOCRINOLOGIC: negative CT results

Objective

Diagnostic results: To examine if the drug had caused adverse effects on her respiratory system, we sent the client to the X-ray scanning. The results showed that her respiratory organs are not affected. Urinalysis test was also carried, and there was no presence of either proteins or fungi in the urine. A psychiatric evaluation was also done, and her mood was fine (Fathi et al., 2020). Attention test was carried out, and the client scored an excellent grade showing that her concentration is back to normal (Goldstein-Piekarski et al., 2016). A one-step test was carried on her using to test the presence of THC metabolites in her urine. The results were negative.

Assessment

Mental Status Examination: JM is a 16-year-old who appears as her reported age. She is interested in the examination. She is clean and neatly dressed. No signs of abnormal motor activities were observed. She has a clear vision, good speech, her tone is normal, she speaks in moderate volume. She does not report auditory/visual hallucination, denies suicidal ideation and no thoughts of hurting self/others. She reports that her attention and mood disorder is back to normal, alert and oriented to time, person, and place and has adequate insight to situation. She is able to comprehend with her judgement intact. She reports good grades at school. Her concentration is fine. She answers questions well.

Differential Diagnosis:

1. PTSD, looking at client’s history cannabis use due to the breakup with her boyfriend, PTSD will be considered. PSTD is a chronic psychological disorder, which can affect all kinds of individuals, dysregulating and disconnecting them from reality after being exposed to a traumatic event. The syndrome is a conglomeration of various cognitive, behavioral, and physiological disturbances characterized by three symptom clusters, i.e., intrusion, avoidance, and arousal (Kar N. (2011).

The affected individuals may be disconnected emotionally, spiritually, cognitively, socially, and physiologically and this may affect their daily activity, and these traumatic events may be overwhelmingly resulting in experiences of memory distortion stored in the brain (Wheeler, 2014). Some clients can cope with traumatic events, however for some, adaptive coping does not occur, as physiological arousal remains, and recurring memories of the aversive event persist, strengthen, and disrupt normal functioning (Cain, Maynard & Kehne, 2012). The DSM-5 describes PTSD as the result of having been exposed to, witnessing, and or common vulnerability to horrifying circumstances taking place in the life of a friend, family member or one or more of the following events like exposure to severe physical, emotional or mental abuse; violent sexual exposure or the death of a family member (Wheeler, 2014). Once post-traumatic stress disorder (PTSD) is diagnosed, treatment may involve psychotherapy, pharmacotherapy (SSRIs), or both. Many psychotherapists utilize CBT to treat clients with PTSD (Pai, et ai, 2017).

2. Change Disorder with Mixed Anxiety and Depressed mood

Change problem is a pressure related, present moment, and nonpsychotic condition. It happens when an individual encounters inconvenience, pain, unrest, or misery (DSM, 2013). The manifestations of Adjustment problem create when an individual is reacting to a particular occasion or circumstance. Average stressors in Adjustment issue incorporate interruptions of cozy connections separated from deprivation, circumstances that upset general transformation, and occupation misfortunes or disappointments (Zelviene and Kazlauskas, 2018). Average indications of Adjustment problems incorporate Low disposition, trouble, stress, tension, sleep deprivation, helpless fixation, and outrage or problematic conduct (DSM, 2013). Other commonplace manifestations incorporate Loss of confidence, sensations of misery, lacking great alternatives, and feeling disengaged.

3. Mood disorder: this condition impacts the emotions of an individual. A patient with this condition can either be happy or sad for abnormally long periods.

Treatment.

Intuniv 1mg every morning to control attention deficit hyperactivity disorder, Focalin XR 5Mg Po every morning for attention deficit hyperactivity disorder, Seroquel 100mg qhs for mood

Reflections:

DMDD and ADHD are the most common conditions that affect any drug user's quality of life. Patients need to go for counseling sessions to recover from such disorders. I would send the client to a counselor to tackle the issue from a psychiatric point of view. Pharmacology is also essential in tackling such cases. I would also administer Buspirone 20mg BID for mood disorders

References

Bruno, A., Celebre, L., Torre, G., Pandolfo, G., Mento, C., Cedro, C., ... & Muscatello, M. R. A. (2019). Focus on Disruptive Mood Dysregulation Disorder: A review of the literature. Psychiatry Research, 279, 323-330.

Cain, C. K., Maynard, G. D., & Kehne, J. H. (2012). Targeting memory processes with drugs

to prevent or cure PTSD. Expert Opinion on Investigational Drugs, 21(9), 1323–1350. 

doi:10.1517/13543784.2012.704020

Fathi, S., Ahmadi, M., Birashk, B., & Dehnad, A. (2020). Development and use of a clinical decision support system for the diagnosis of social anxiety disorder. Computer Methods and Programs in Biomedicine, 190, 105354.

Goldstein-Piekarski, A. N., Williams, L. M., & Humphreys, K. (2016). A transdiagnostic review of anxiety disorder comorbidity and the impact of multiple exclusion criteria on studying clinical outcomes in anxiety disorders. Translational Psychiatry, 6(6), 847-847

Kar N. (2011). Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a

review. Neuropsychiatric disease and treatment, 7, 167-81.

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to

guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing

Company.

Zelviene, P., & Kazlauskas, E. (2018). Adjustment disorder: current perspectives. Neuropsychiatric disease and treatment, 14, 375–381. https://doi.org/10.2147/NDT.S121072