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Week 4: Focused SOAP Note and Patient Case Presentation

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan 1

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Introduction

An individual's psychiatric examination should be complete and integrated.

crucial in the development of a correct psychiatric diagnosis Facts must be gathered from

numerous sources without bias in order to receive reliable knowledge. The goal of this

assignment is to gain an understanding of important questions to ask during an assessment and

how to effectively assess and diagnose a mood disorder based on information acquired from the

patient and objective information obtained during an interview by the PMHNP. After

interviewing the patient, the assessment was noted, and three differential diagnoses were

developed based on the information gathered during the interview session. A PMHNP was

referred to a 26-year-old White female patient for treatment and continued management of her

mental health problem.

CC: “I have a history of taking medications and stopping them; I think the medication squashes

who I am".

HPI: J.P a 26-year-old White female who came in for medication management. Patient

is currently taking Zoloft which she complains made her high when she is creative and while

sleeping her mind will be racing. She also takes Risperidone which made her gain weight. Takes

Seroquel which made her gain weight as well, Klonopin, she complained it slowed her down.

Because of the above listed discomfort and side effects patient listed, patient stopped taking the

medication.

Substance History or Current use: Nicotine: smoke about a pack cigarette a day and will

not quit. Alcohol: admits to drinking alcohol but that was 19 years ago. Used marijuana some

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years ago and got paranoid, stopped smoking it. Cocaine and other stimulants: denies use.

Caffeine: denies. Sedatives: Denies. Denies use of mushrooms. Denies use of pain pills or street

drugs. Denies use of any type of ecstasy drugs.

Family Psychiatric: Mother had bipolar, Father was arrested and had jail time in prison due to

drugs for 10 years now. Brother has schizophrenia but never went to hospital for treatment. No

family history of suicide. Patient admits that she tried to kill herself once in the past but I won't

do it again.

Psycho-social History: Lives: lives with her mother and sometimes her boyfriend. Goes over to

her mother if her boyfriend’s gets mad at her for sleeping around. Work: employed; works with

aunt's bookstore. Misses work when she is feeling low. Education: in school for cosmetology to

do make up for movie stars. Fun activities: writing her life story, paints Picasso. Arrest: police

picked patient up and took her the hospital that she was found dancing naked. Trauma: Father

was pretty tough and yelled at them a lot. Raised by mother and older brother.

Hospitalization: Patient have been admitted four times. Admitted for suicide

ideation: overdosed with Benadryl in 2017. When patient was a teenager, went for some days

without sleeping. They gave patient some medication in the hospital that she can’t remember the

name.

Psychiatric History: Depression, Anxiety, Bipolar. Depression: get depressed for about 4 to 5

times a year; when patient does not have any energy or creativity then patient feels depressed and

not want to do anything. During those episodes, are times when patient does not take her

medication. Patient denies being having anxiety at this time. Denies repetitive episodes or OCD.

Denies AVH/Delusions. Only hallucinates when she is not sleeping well; she hears voice. But

none at this time. Appetite: when creative she is too busy to eat, when she is crashing, she eats a

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lot. Bad dreams: denies bad dreams. Sleep: 5 to 6 hours. When creative sleeps for 3 hours a

week. When crashing can sleep for 12 to 16 hours a day.

Current Medication: Zoloft, Risperidone, Seroquel, Klonopin, pregnancy control pill

Allergies: NKDA

Reproductive History: patient is sexually active. Patient states that she likes to have a lot of

sex and it makes her feel high. Takes birth control pill for PCO. Her birth control is regular

type.

Medical history: Hypothyroidism, PCO

ROS:

GENERAL: feeling warm, no chills, no fatigue

HEENT: Eyes: Vision intact, yellow sclerae. Ears: positive earache, positive hard of hearing,

Nose: denies runny nose, sneezing, or congestion, Throat: no sore throat.

SKIN: Warm to touch, No rash

CARDIOVASCULAR: No chest pain, No palpitations, or edema.

RESPIRATORY: No shortness of breath, negative for cough or hemoptysis

GASTROINTESTINAL: Occasional constipation, No nausea, vomiting, or diarrhea. No

abdominal pain, no blood stool

GENITOURINARY: denies any problem with urination or bladder

NEUROLOGICAL: frequent headache, no syncope, numbness, or tingling in the extremities.

MUSCULOSKELETAL: occasional should and back pain, No muscle, joint pain, or stiffness.

HEMATOLOGIC: No anemia or bleeding disorder

LYMPHATICS: No enlarged nodes.

PSYCHIATRIC: a history of bipolar, depression

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ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or

polydipsia.

Diagnostic results: No diagnostic test or labs needed during the session

Assessment

Mental Status Examination

J.P. is orientated four times. During the interview, you must be able to correctly answer

questions, follow orders, and remain alert. She is also nice and neurologically sound. Her mood

is balanced but dysthymic. She responds to all questions and goes into great depth when

necessary. Although there were no acute psychosis or mood symptoms, the patient appeared

concerned. Denies any current or previous history of suicide. Denies having any homicidal ideas

or hearing voices or thoughts that might cause harm to people. All of your memories are still

intact.

Diagnostic Impression

Bipolar Disorder: The following diagnosis is based on the information supplied and is subject

to change as new data becomes available during later sessions. Bipolar disorder also known as

manic-depressive illness or manic depression, is a mental condition that causes erratic mood

swings, energy, activity levels, focus, and the ability to perform daily chores. People with bipolar

illness have times of exceptionally high mood, changes in sleep patterns and activity levels, and

uncommon actions, which they don't always recognize as harmful or undesired. The term "mood

episodes" refers to these separate intervals (Bachem & Casey, 2018). To be diagnosed with a

bipolar disorder, an individual must meet specific criteria, according to the DSM-5. Within two

weeks, the patient must experience 5 or more of the following symptoms: A distinct time of

abnormally and persistently high, expansive, or irritable mood, as well as abnormally and

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persistently heightened activity or energy, that lasts at least 4 days and is present virtually every

day (American Psychiatric Association, 2013). Our patient J.P presented with symptoms and

behavior that correlates with the above listed symptoms: patient states that she get depressed

for about 4 to 5 times a year; when patient does not have any energy or creativity then patient

feels depressed and not want to do anything. During those episodes, are times when patient does

not take her medication. Patient states that she likes to have a lot of sex with different people,

even though she has a boyfriend, that it makes her feel high. Patient smoke about a pack cigarette

a day, said she is planning to quit. Admitted for suicide ideation: overdosed with Benadryl.

Patients works in her aunt’s bookstores but can stay away as she likes she does not feel like it.

Borderline Personality Disorder: Borderline Personality Disorder is a major mental health

condition with no recognized etiology. Individuals with Borderline Personality Disorder have

continuous mood swings, self-image issues, impulsive behavior, and trouble relating to others,

even animals (Sadock, et al., 2015). A pattern of changing moods, self-image, and behavior

characterizes borderline personality disorder. Impulsive behavior and relationship issues are

common outcomes of these symptoms. Anger, despair, and anxiety can persist anywhere from a

few hours to days in people with borderline personality disorder. According to the DSM-5, the

patient must have experienced these symptoms for at least 6 months: disabling episodes of anger,

depression, and anxiety that last for hours or days, problems controlling anger, difficulty trusting,

irrational fear of other people's intentions, feelings of dissociation, and feelings of emptiness;

intense episodes of anger, depression, and anxiety that last for hours or days; problems

controlling anger, difficulty trusting, irrational fear of other people's intentions, feelings of

dissoci (American Psychiatric Association, 2013). The above-listed symptoms are evident in J.P

our patient as evidenced by patient get depressed for about 4 to 5 times a year; when

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patient does not have any energy or creativity then patient feels depressed and not want to do

anything. During those episodes, are times when patient does not take her medication. Patient

states that she likes to have a lot of sex with different people, even though she has a boyfriend,

that it makes her feel high. Patient smoke about a pack cigarette a day, said she is planning

to quit. Admitted for suicide ideation: overdosed with Benadryl. Patients works in her aunt’s

bookstores but can stay away as she likes she does not feel like it.

Generalized Anxiety Disorder:

Reflection

CBT treatment recommendation

Case Formulation and Treatment Plan

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