NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Week # 7 Comprehensive Psychiatric Evaluation
LO
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
PMHNP/FNP
January11th, 2023
OBJECTIVES
1. Perform a thorough complete psychiatric evaluation.
2. Choose the best possible primary diagnosis.
3. Analyze the best pharmacology and nonpharmacological Options
4. Provide community resources.
Subjective:
CC (chief complaint): “I’m here because my doctors and mom are worried about my mood. I’m always sad, overwhelmed, and anxious about my new baby and I cry often. I am struggling with this new baby.”
HPI:
K.A. is a 16-year-old Hispanic female that presents to the office today with her mother for initial intake. The patient verbalized that she had a baby two months ago but has been suffering from sadness, hopelessness, guilt, and frequent crying. She reports that she felt sad and depressed when she found out she was pregnant but that the feelings of worthlessness and helplessness with periods of anxiety have increased since giving birth two months ago. She states “sometimes I don’t want to get out of bed to do anything but now this baby is making it difficult for me able to do what I want. She feels guilty for letting her family down because had big hopes for her. She reports that when the baby cries she gets tremors, increased heart palpitations, and sweating spells. She also complains of frequent headaches, body aches, and tension. Mom reports that she is concerned with the client’s well-being because she is sad and cries when she fails to take care of the baby. Sometimes she does not sleep because she thinks something will happen to the baby. The client’s mom reports that she has to remind her several times to take a bath and groom herself otherwise she can stay in her pajamas for days. She forgets to provide care for the baby and is scared and anxious when the baby cries. The client denies suicide ideation or hallucinations. She denies any alcohol or substance use. She denies any past psychiatric history. She denies any family psychiatric history or hospitalizations.
Substance Current Use: Patient denies substance use, alcohol or cigarette smoking
Past Psychiatric History: K.A denies any past psychiatric history or hospitalization
·
General Statement: K.A. is sad, tearing up occasionally, and feels hopeless, worthless, withdrawn, and anxious at times.
·
Caregivers (if applicable): Mother
·
Hospitalizations: None
·
Medication trials: K.A denies any medication history
·
Psychotherapy or
Previous Psychiatric Diagnosis: Denies any psychiatric history
Substance Current Use and History: Denies drugs, alcohol, and cigarette smoking.
Family Psychiatric: Denies any past psychiatric history or family history
Psychosocial History:
The client verbalized that she was in 10 th grade going to 11 th when she found out she was pregnant. She is still with her boyfriend but is currently not sexually active and not on any birth control
. She reports that she is very tired all the time because the baby does not sleep at night and cries a lot. She misses her friends from school but their parents don’t want them to play with her since they found out she was pregnant. Her cousins also no longer visit her. she reports that she no longer has any hobbies. She feels she has no time for herself. She lives with her mom and two younger siblings. Her father is not in her life, her parents got divorced when she was very young. Her only support system is her mother and boyfriend but her mother works long shifts and therefore can only offer limited help.
Medical History: Denies use of alcohol, drugs, or smoking
·
Current Medications: Prenatal vitamins
·
Allergies:
Honey- nausea/ vomiting
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Reproductive Hx:
Sexually active since 15 years old. Has a two-month-old baby.Is currently not sexually active since the birth of the baby. Not on birth control.
ROS:
GENERAL:+Insomnia, fatigue, sadness, emotions with sobbing and periods of anxiety, no fever, chills, or weakness
.
HEENT: Eyes: K.A. wears eyeglasses and contacts; she denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: K.A. denies rash or itching.
CARDIOVASCULAR: K.A. denies chest pain, chest pressure, or chest discomfort. + occasional palpitations and 1+ edema to bilateral feet due to pregnancy.
RESPIRATORY: K.A. denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: K.A. reports poor appetite, and denies nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: K.A denies burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: K.A. verbalized headaches, and denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: K.A. denies muscle, or back pain, joint pain, or stiffness.
HEMATOLOGIC: K.A. denies any anemia, bleeding, or bruising.
LYMPHATICS: K.A. denies enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: K.A. denies sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results:
B/P 130/76 Pulse 78 Respiration 18 Temp 98.9 F weight 150 lbs.
PHQ-9 assessment was completed and reviewed, score = 18, indicative of moderate-severe depression. Over the prior two weeks, the patient endorsed having problems with sleep, energy, and appetite nearly every day and interest and mood for several days. The patient denied having problems with suicidal ideation, or thoughts of self-harm over the past two weeks.
GAD-7 assessment was completed and reviewed in session, score = 14, indicative of moderate anxiety. The patient reported having anxiety and fear of something awful happening nearly every day, having uncontrollable worrying for more than half of the days, and having widespread worrying, trouble relaxing, and irritability for several days over the last two weeks. The patient denied having restlessness over the last two weeks.
Stressors
Areas of stress included the following: severe stress due to family, relationship, and childcare concerns, moderate stress due to economic, occupational, and educational concerns, and mild stress due to nutrition concerns. There was no stress reported in the following areas: housing and legal concerns.
Assessment:
Mental Status Examination:
K.A. is a 16-year-old Hispanic Female that is two months postpartum and is age appropriate. She is alert and oriented x 4 with good insight and concentration but appears sad, emotional, and withdrawn with crying outbursts at times. K.A. is answering questions appropriately and is cooperative with the examiner. She is well-groomed, clean, and dressed appropriately for the season. She is fidgety and shifts her position in her chair often. Makes good eye contact and her speech is slow, soft monotone but clear with fluctuating tone and pitch. Her affect is congruent but sad.No pressured speech, flight of ideas, or looseness of association. The mood is sad, depressed, restless, and anxious. She denies any auditory or visual hallucinations or delusions. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation.
Diagnostic Impression:
Major Depressive disorder with Postpartum onset
Up to 80 percent of women who have given birth experience the “baby blues” or the “fourth-day blues”. Postpartum depression (PPD) is more severe and longer lasting. PPD can affect the The ability of the mother to care for her child and herself which is a potentially life-threatening physical and emotional condition characterized by depression-like symptoms that occur from a month to a year after childbirth and is thought to be caused in part by dramatic hormonal shifts that occur during childbirth (Piotrowski, 2021). The DSM 5 states that five (or more) of the following symptoms must be present at least one of which is either a depressed mood or lack of interest or pleasure-have appeared over the course of the same two-week period. Subjective symptoms include feelings of sadness, emptiness, hopelessness, or crying the majority of the time, almost every day with markedly lowered interest or enjoyment in practically all activities with the onset of childbirth (American Psychiatric Association, 2013). The patient met the diagnostic criteria for major depressive illness, according to the DSM 5. She complained of a change in her mood, a loss of interest in friends and almost all activities, weight gain, insomnia, and a lack of concentration. This is my primary diagnosis because the patient’s mood and behavior shifted after childbirth and the results of het PHQ-9.
Generalized Anxiety Disorder (GAD)
Generalized Anxiety Disorder (GAD) is a condition in which a person struggles with excessive and overwhelming worrying over anything small or big. The individual’s daily life must be impacted negatively by the presenting symptoms, which must manifest every day for at least six months according to the DSM 5(American Psychiatric Association, 2013). K.A. reported that her symptoms of worrying and panicking started when she found out she was pregnant and it has increased tremendously with the delivery of her baby. She states that she worries that something bad might happen to her or the baby especially when she falls asleep. The results of the GAD 7 conducted in session on this client yielded a result of 14 which is indicative of moderate anxiety. Her home, social, and school life have been negatively impacted by her symptoms of worrying, restlessness, sweating, and heart palpitation. She meets the DSM-5 criteria for the diagnosis of
generalized anxiety disorder according to the symptoms she is manifest
Adjustment Disorder With mixed anxiety and depressed mood:
The DSM 5 describes adjustment disorder as the appearance of emotional or behavioral symptoms in reaction to a stressor within three months of the stressor’s initiation. Clinically relevant manifestations of these symptoms or behaviors include one or both of the following taking into account the external context and any cultural elements that may have an impact on the degree and presentation of the symptoms, marked distress that is out of proportion to the severity or intensity of the stressor or significant dysfunction in social, academic, or other key aspects of functioning (American Psychiatric Association, 2013). A combination of depression and anxiety is predominant with adjustment disorder. K.A. has both the symptoms of depression and anxiety disorders, therefore, she satisfies this diagnosis. She repeatedly discloses how she is struggling to accommodate the baby and how she is failing to care for the baby.
Case Formulation and Treatment Plan:
My Preceptor and I reviewed the results of her assessments, PHQ-9 and GAD-7 were discussed with the client and her mother in session and were given the opportunity to ask questions. K.A. was given the option of medication and psychotherapy based on her results of PHQ9 and GAD 7 scores. The client declined all medication and insists that she wants to breastfeed, and does not want medication at this time. The medication of choice was Zoloft 50 mg because it is an effective SSRI and one of the few medications that are safe to be taken while breastfeeding (Molenaar, et al., 2018). Information on Zoloft was provided to her to think about it and can be discussed again at next week’s appointment. The patient was encouraged to start psychotherapy particularly cognitive-behavioral therapy (CBT) because it will help to lessen symptoms of depression and anxiety disorders (Beal, 2021). CBT will help K. A improves emotional regulation and creates specific coping strategies that are aimed at resolving her present issues of hopelessness, anxiety, and fear (Beal, 2021). K.A. was educated on post-postpartum blues and provided with information on Social support for new moms with postnatal education which is essential in terms of the prevention of future pregnancies and depression. The loving support of a spouse or partner, relatives, and close friends is extremely helpful ( Sprague, 2021). The client and mother agreed to devise a plan to help the client with the baby so she can get more sleep. Coping mechanisms were reviewed in sessions with proven steps to manage anxiety and mood. The special supplemental nutrition program called Women, Infants, and Children (WIC ) was given to clients because they offer to screen for depression and provide treatment referrals while teaching proper feeding techniques and strategies (Weinfield & Anderson, 2022).
K.A.‘s social determinants of health are quite a few because teenage pregnancy and births pose many challenges that require collective efforts to provide solutions. Efforts to reduce teen pregnancy are mainly focused on prevention, and sex education is a large part of the effort. Research shows that reducing the number of births to teens and increasing the age at which a woman gives birth yields significant cost savings (Piotrowski & Benson, 2022). The patient was referred to her OB /GYN for birth control measures because she is currently not on any birth control and is still dating her boyfriend. K.A. was given information on how to enroll in WIC to get assistance with nutrition for herself and the baby. She was encouraged to join a support group for teenage mothers. The patient was given a follow-up appointment in a week to think about all the information discussed in the session. She contracted for safety. A lab slip for a CBC, BMP, and TSH was given to the patient to complete before the next appointment. Instructed her to call the office with any questions or call 911 with any emergencies.
The Following Resources were Girven to the Patient:
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Helping Teen Parents and Their Children Build Healthy Futures
Community Support for Young Parents
Reflections:
I agree with the comprehensive and thorough assessment my preceptor conducted and I would not change anything. My preceptor did a great job engaging the patient in the whole treatment plan and process. The patient was given adequate information about the medication and nonpharmacological treatment options to arrive at her decision. At the beginning of the session, the patient and her mother gave informed consent to be treated and informed that everything discussed in the meeting will be kept confidential(Bipeta, 2019).
It is vital that healthcare providers communicate with the patient in a manner that is nonjudgmental. It is equally important to remember that depending on the patient encounter the examiner might not be able to collect the global picture of the patient’s history which includes social, genetic, and environmental factors (Saddock et al., 2015). My preceptor educated me that it is important to get as much information as possible but that not everything might be covered in the first meeting and that is why the next follow-up is in a week’s time. I learned that you have to give the patient adequate time to arrive at their decision. At the next follow up the patient stated that she was feeling much better after the first meeting with my preceptor and her first session with the therapist. She confirmed that she wants to continue breastfeeding her baby and will not be considering medication at this time.
Questions
1. Do you agree with my differential diagnoses? and if not, please provide your suggestion.
2. What is your opinion about the patient’s decision to refuse medication?
3. What other support and community resources would you offer this patient?
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Beal, D. G. (2021). Cognitive behavior therapy (CBT). Salem Press Encyclopedia of Health.
Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of
Psychological Medicine, 41(2), 108-112.
https://doi.org/10.4103/ijpsym.ijpsym_59_19
Carroll, C. M. (2021). Generalized anxiety disorder (GAD). Salem Press Encyclopedia of Health.
Community Support for Young Parents. (n.d.). HHS Office of Population Affairs. Retrieved January 10, 2023, from
https://opa.hhs.gov/grant
–
programs/pregnancy
–
assistance
fund/paf
–
successful
–
strategies/community
–
support
–
young
Journal of the American Academy of Psychiatry and law. (n.d.). Document on principles of informed consent. Journal of the American Academy of Psychiatry and the Law.
https://jaapl.org/content/jaapl/25/1/121.full
Driessen,E., Van, H. L., Peen, J., Don, F. J., Twisk, J. W. R., Cuijpers, P., & Dekker, J. J.
M. (2017). Cognitive-Behavioral Versus Psychodynamic Therapy for Major Depression: Secondary Outcomes of a Randomized Clinical Trial. Journal of Consulting Clinical
Helping Teen Parents and Their Children Build Healthy Futures. (n.d.). HealthyChildren.Org. Retrieved January 10, 2023, from
https://www.healthychildren.org/English/ages
stages/teen/dating
–
sex/Pages/Teen
–
Parents.aspx
Molenaar, N. M., Kamperman, A. M., Boyce, P., & Bergink, V. (2018). Guidelines on treatment of perinatal depression with antidepressants: An international review. Australian & New
Zealand Journal of Psychiatry, 52(4), 320–327.
https://doi.org/10.1177/000
486741876205
Piotrowski, N. A., PhD, & Benson, A. K., PhD. (2022). Postpartum depression. Magill’s Medical Guide (Online Edition).
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11thed.). Wolters Kluwer.
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) | Food and
Nutrition Service. (n.d.). Retrieved January 10, 2023, from
https://www.fns.usda.gov/wic
Sprague, C. (2021). Teen Pregnancy. Salem Press Encyclopedia.
Weinfield, N. S., & Anderson, C. E. (2022). Postpartum Symptoms of Depression are Related to
Infant Feeding Practices in a National WIC Sample. Journal of Nutrition Education and Behavior, 54(2), 118–124. https://doi.org/10.1016/j.jneb.2021.09.002
© 2021 Walden University Page 1 of 9
© 2021 Walden University Page 1 of 9
© 2021 Walden University Page 1 of 9
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week 7 Discussion GO
Walden University
PRAC 6675 Across the Lifespan
January 11, 2023
Subjective:
CC (chief complaint): the patient JP reports trouble dealing with anxiety, depression, anhedonia and worrying about school as well as lack of energy.
HPI: The patient JP is a 17-year-old caucasian male that presented to the clinic for a follow-up appointment for the management of his anxiety, depression, and lack of energy. He arrived at the office today with his mother. JP’s first sought treatment at the age of 15 related to his anxiety and depression. At this time, he started falling behind in school and had difficulty keeping up. At the age of 15, he was started on Zoloft, but after about six months did not see much improvement in the symptoms and stopped the medications. The patient has not seen another prescriber since the age of 15. The patient first presented to our clinic about three months ago and since then has been initiated on Effexor and has since been titrated to 112.5 milligrams PO qday. The patient reported an improvement in his symptoms when initiated on 37.5 milligrams qday but only started seeing efficacy when the dosage was titrated to 112.5 milligrams qday. The patient rates his mood to be a 6 out of 10 compared to previous scores of three on the last office visit.
Substance Current Use: JP denies any nicotine use. He does report that at the age of 16, he experimented with drinking alcohol socially with peers on the weekends. He stated that in one sitting, he would have ten beers. The patient states that he has not had any alcohol in approximately six months now. The patient denies any additional recreational drug use. the patient denies any caffeine use.
Medical History:
·
Current Medications: Effexor 112.5 mg PO qday
·
Allergies:
no known drug allergies, no known food or environmental allergies.
·
Reproductive Hx:
Denies current or previous sexual activity.
ROS:
· GENERAL: the patient denies any recent weight loss or weight gain. The patient has no complaints of fevers or chills. The patient denies any changes in his energy levels. The patient reports that he’s able to sleep approximately 6 to 8 hours nightly without interruption.
· HEENT: The patient’s head is symmetrical with no obvious deformities. The patient has no discharge of the eyes, ears, or nose. Throughout the interview, is not noted that the patient had any productive cough or trouble breathing. The patient denies any history of head injuries. The patient also denies any visual disturbances, including double vision or blurry vision.
· SKIN: the patient’s skin is normal for ethnicity with no rash observed.
· CARDIOVASCULAR: The patient denies any chest pain or chest discomfort. There is no note of any edema in any extremities. The patient denies any history of heart palpitations.
· RESPIRATORY: The patient can talk in complete sentences without shortness of breath. Throughout the interview, there was no evidence of a cough or the production of sputum.
· GASTROINTESTINAL: The patient denies any nausea, vomiting, or diarrhea. The patient’s abdomen is flat and nontender. The patient denies any bloody or tarry stools.
· GENITOURINARY: The patient denies any dysuria or odor coming from his urine. The patient also denies any issues with hesitancy or urgency while urinating.
· NEUROLOGICAL: The patient is alert and oriented times 4 denying any headaches. The patient has equal movement and sensation to all extremities. The patient is also able to ambulate in a steady gait. The patient denies any loss of control of bowel or bladder function.
· MUSCULOSKELETAL: The patient is able to ambulate with a steady gait with no report of backward joint pain.
· HEMATOLOGIC: the patient has no history of abnormal bruising or bleeding. The patient’s last CBC was found to be within normal limits. The patient denies any history of anemia.
· LYMPHATICS: The patient had no enlarged lymph nodes, and the patient reports that they have not had any previous surgeries before.
· ENDOCRINOLOGIC: The patient denies polyurea, polydipsia, and polyphagia. The patient also denies any intolerances to heat or cold.
Objective:
Diagnostic results: vitamin B, vitamin D, CBC, CMP
Vital signs
blood pressure126/70, pulse 70, respiratory rate16 brass a minute, temp 98.4 F
Assessment:
Mental Status Examination:
JP is a 17-year-old caucasian main that appears to be of the stated age. During the interview the patient is calm and cooperative during the exam. The patient is casually dressed and appropriate for the weather today. There was no note of any extra parietal movements from the patient. the patient’s speech is of proper volume and rate. The patient’s thought process is linear, logical, and goal-directed. The patient’s mood is good, and the affect is congruent and full range. The patient denies any suicidal or homicidal ideations. The patient also denies any auditory or visual hallucinations. The patient is alert and oriented times four. The patient can recall both remote and recent memories. The patient has good insight into his disease process as well as the treatment plan.
Diagnostic Impression:
Major depressive disorder-the most likely diagnosis for this patient is a major depressive disorder. The patient is exerting a low or depressed mood, as well as decreased interest in enjoyable activities, a lack of energy as well as changes in his appetite, and these are all symptoms that coincide with major depressive disorder (Akkasheh et al., 2022). Since starting on the new medication, Effexor, the patient’s mood has significantly improved as well as his energy. Psychotherapy, in combination with pharmacological approaches has been shown to be the most effective for managing this disorder(Guidi & Fava, 2021).
Generalized anxiety disorder-our patient was also having significant difficulty managing his school work and was reported that it was from his anxiety and feeling overwhelmed. Generalized anxiety disorder usually manifests with excessive unrealistic worrying about common everyday things (Demertzis & Craske, 2022). These symptoms can be debilitating, and in this patient, the situation calls them to fall behind significantly in school as well as in their personal life. It is likely that this patient is suffering from both major depressive disorder and generalized anxiety disorder, and some studies have found that as much as 41.6% of patients suffering from the major depressive disorder also suffer from generalized anxiety disorder period (Kalin, 2020).
Borderline personality disorder-after discussing with my preceptor, I also found that the patient may potentially have a borderline personality disorder. The patient has many traits that coincide with a cluster B borderline personality disorder. Patients that are suffering from this disorder suffer from pervasive patterns of effective instability as well as difficulty with interpersonal relationships (Kulacaoglu & Kose, 2018). There were talks of continuing to assess for this and get confirmation with neuropsychological testing.
Reflections:
I was fortunate that I was able to follow this patient’s treatment plan from the beginning And was present when his follow-up appointments. It was interesting how the patient had previously failed a trial of an SSRI for managing the major depressive disorder and generalized anxiety disorder. Typically SSRI’s are the first line of treatment for any patriot depressive disorder or generalized anxiety disorder.
After the patient failed to achieve efficacy with the trial of Zoloft, I found it to be interesting that the provider went straight to Effexor. Considering the patient’s age and single trial of 1 SSRI, I may have considered using another SSRI before giving up on that drug class.
Knowing the patient’s ability to utilize vitamin B properly could also be a good indicator of why the patient failed to achieve efficacy with Zoloft. Patients that have the inability to utilize vitamin B properly or have low levels of vitamin B have been shown to not respond as well to SSRIs. Sometimes as simple as adding a vitamin B supplement may help to improve the patient’s ability to properly metabolize SSRI’s.
The patient was referred to psychotherapy, and it would have been good to collaborate more with the therapist on what they’ve been working on. Having a better understanding of what the therapist has been working on can help to facilitate better proper medication management and develop a more rounded treatment plan.
Getting additional information from the patient’s teachers at school can be helpful in properly diagnosing patients. Understanding how others perceive the individual outside of the clinic can also be helpful in properly assessing, diagnosing, treat patients. Sometimes it is possible that a patient act entirely differently in different settings. Being that this is a school-age kid, this is another resource that we could have tapped into.
Case Formulation and Treatment Plan:
Providing the patient with the emergency crisis hotline if he feels suicidal.
Educate the patient about the available resources in the neighborhood, including the local crisis center end emergency rooms if needed for emergency events.
Educate the patient to use 911 if he is having a medical emergency, including suicidal ideation.
Allow time for interviewing both the parents and the patient during each visit independently.
Continue to titrate the patient’s medications as needed to reach efficacy related to the patient’s anxiety and depression while assessing for adverse reactions.
Consider the usage of neuropsychological testing to rule out other disorders, such as personality disorders.
Utilize both the patient and the family 4 obtain a more detailed history of the patient and family.
Encourage the development of coping skills, including utilizing resources such as friends and family to talk to when having difficult times.
Continuing psychotherapy for management of major depressive disorder and anxiety.
Continue to collaborate with the patient’s primary care provider.
Have labs drawn as listed above to rule out another physiological rationale for the patient’s symptoms.
Questions for Classmates
1. What additional nonpharmacological recommendations would you have for a patient suffering from major depressive disorder and or generalized anxiety disorder?
2. Do you agree with my preceptor’s recommendation to change his medication from Zoloft to Effexor? What other medications would you have considered prior to starting Effexor after the failed trial of Zoloft?
3. For patients suffering from major depressive disorder, how would your treatment plan differentiate from an adolescent to an adult?
4. What resources are available in your area to assist patients that are suffering from suicidal ideation or an exacerbation of their depressive symptoms?
References
Akkasheh, G., Kashani-Poor, Z., Tajabadi-Ebrahimi, M., Jafari, P., Akbari, H., Taghizadeh, M., Memarzadeh, M., Asemi, Z., & Esmaillzadeh, A. (2022). Major depressive disorder. Nutrition (Burbank, Los Angeles County, Calif.), 32(3), 315–320.
Demertzis, K. H., & Craske, M. G. (2022). Generalized anxiety disorder. Practitioner’s Guide to Evidence-Based Psychotherapy, 301–312. https://doi.org/10.1007/0-387-28370-6_30
Guidi, J., & Fava, G. A. (2021). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder. JAMA Psychiatry, 78(3), 261.
Kalin, N. H. (2020). The critical relationship between anxiety and depression. American Journal of Psychiatry, 177(5), 365–367.
Kulacaoglu, F., & Kose, S. (2018). Borderline personality disorder (bpd): In the midst of vulnerability, chaos, and awe. Brain Sciences, 8(11), 201. https://doi.org/10.3390/brainsci8110201
© 2021 Walden University Page 1 of 3
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
S K
College of Nursing-PMHNP, Walden University
PMHNP Across Lifespan II Pract-Winter 2022
01/11/2023
Subjective:
CC (chief complaint): Attempted suicide
HPI: A.P. is an 24-year-old African American presenting with a chief complaint of attempted suicide. The patient was admitted for a cocaine overdose. The patient exhibits symptoms of short temper, irritability, mood swings, and intense anger. He also reports binge drinking and eating. The patient exhibits marked impulsivity and irrational behaviors. The patient’s mother says he mainly talks about death and threatens to jump off the balcony. She also reports that A.P. has episodes of variable moods that last for a few hours. A.P. reports experiencing recurrent thoughts of suicide and feeling worthless.
A.P. dropped out of college and stayed at home with his younger brother, who is physically disabled. The patient also has a pattern of intense relationships that do not last long. He recently ended his intimate relationship abruptly. He also cut family ties with his father and step-siblings and avoids his extended family members and friends. Additionally, the patient is distressed and wishes his suicide attempt was successful. The patient has a previous history of attempted suicide. He has had several burns and cuts on his arms. A.P. has also tried harming his younger brother when angry. He reports reckless driving when unable to control his anger. The patient has a DUI report and was convicted of physical violence when drunk. He lost his first job due to binge drinking and irrational behaviors.
The patient was diagnosed with depression at 18 years old. He was under antidepressants but discontinued therapy and treatment seven months ago after quitting college. A.P. has a family history of bipolar disorder. His maternal grandmother had a history of anxiety and depression. The patient’s maternal uncle has a history of cocaine abuse and died from an overdose. His father also smokes tobacco and has a history of diabetes. A.P. was exposed to unstable invalidating relationships in his childhood. He was raised by a single mother who had on-and-off intimate relationships. The patient also experienced abandonment at age 12. He reports temporarily living under foster care.
Substance Current Use: The patient smokes tobacco (2 packets per day) and abuses cocaine. He is also a binge drinker (7 bears per day). He has a history of marijuana abuse.
Medical History:
·
Current Medications: The patient is currently not under any medication or psychotherapy.
·
Allergies:
The patient is protein intolerant and experiences hives, itching, and eczema. He reports milk, eggs, and peanut allergies. He is also allergic to pet dander and exhibits nasal congestion and uncontrollable sneezing. He has no known drug allergies.
·
Reproductive Hx:
The patient is sexually active. He has no child nor a history of vasectomy.
ROS:
· GENERAL: The patient appears generally healthy. He denies general body pain, fatigue, and cognitive issues.
HEENT: The patient has a 2-year-old scar on his head and a lesion behind his neck. He denies any recent changes in vision, difficulty hearing, tinnitus or vertigo, throat discomfort, and airway congestion. The patient has red eyes and brown teeth.
· SKIN: The patient has pale skin and yellow stains on the nails and fingers. He also has self-injury scars on his left arm, palm, phalanges, and back neck.
· CARDIOVASCULAR: The patient denies any history of hypertension or other cardiac issues. He also denies any history of swelling of the extremities and unexplained fatigue.
· RESPIRATORY: He denies any history of respiratory diseases or breathing difficulty. He has no symptoms of coughing or wheezing.
· GASTROINTESTINAL: A.P. has no history of ulcerative colitis or GERD. He denies symptoms of abdominal pain, nausea, and vomiting. The patient has no complaints of constipation or diarrhea. He reports increased appetite and binge eating habits.
· GENITOURINARY: The patient has no history of genitourinary issues, dysuria, or bladder infections.
· NEUROLOGICAL: The patient has neurological dysfunction. He exhibits symptoms of dissociation and cognitive impairment.
· MUSCULOSKELETAL: The patient has good reflexes and remains alert. He has no history of musculoskeletal conditions. He reports pain in his left foot joint attributed to an attempted suicidal jump off the roof.
· HEMATOLOGIC: The patient has no complaints of nose bleeding. He has a history of blood clots in his limbs.
· LYMPHATICS: The patient has sharply edged and palpable lymph nodes. He has no complaints of swollen ganglia or pain during palpation.
· ENDOCRINOLOGIC: He has no history of hyperthyroidism
Objective:
Diagnostic results: B.P.: 144/9 mmHg, Pulse: 72 bpm, R: 14 breaths/min, T: 98.6°F
Assessment:
Mental Status Examination: The patient has a pattern of irrational behaviors. He portrays risky habits and repeated suicide attempts and ideation. Additionally, the patient’s debilitating symptoms and unhealthy behaviors affect his social life. He has made irrational decisions, such as quitting college and ending his family, friends, and intimate relationships. Furthermore, the patient is alert but has dissociation symptoms that affect his concentration. His history of differing treatments raises concerns about poor adherence to pharmacotherapy and psychotherapy.
Diagnostic Impression: A.P.’s primary diagnosis is borderline personality disorder. This diagnosis is relevant because the patient has a history of depression, a predisposing factor (National Institute of Mental Health, 2022). The patient also meets the DSM-5-TR diagnostic criteria for borderline personality disorder, which includes social instability, repetitive patterns of unstable relationships, several suicide attempts, and impulsivity (The Diagnostic and Statistical Manual of Mental Disorders, 2013). The patient has a history of suicide attempts and reports suicide ideation. Additionally, he has scars from self-injury and a past of causing harm to people around him. The patient also exhibits symptoms of irrational behavior, such as binge drinking, eating, and driving recklessly under the influence. He has also experienced abandonment and was exposed to an unstable relationship. Furthermore, the patient’s symptoms have affected his social life and productivity.
The patient is likely suffering from depression. The rationale is that he has a previous diagnosis of depression and a family history of depression. Additionally, the patient deferred treatment seven months ago. He also reports distress, mood swings, and difficulty controlling anger and emotions. He also has chronic feelings of emptiness, worthlessness, and suicidal ideation. However, this diagnosis is ruled out because the patient does not meet the diagnostic criteria. A.P. does not experience depression episodes consecutively for at least two weeks (National Institute of Mental Health, 2021). The patient’s symptoms of mood swings and angry outbursts only last for a few hours. He has no symptoms of mania or depression. Additionally, the patient has no persistent distress, and his clinical symptoms indicate personality issues such as irrational decision-making.
Another differential diagnosis is post-traumatic stress disorder. The patient exhibits symptoms of a short temper, intense anger, and irritability. He also has several suicide attempts and a history of substance abuse. The patient has self-injury scars and reports suicide ideation. Additionally, he has a family history of complete suicide and exposure to abandonment, and family instability. These traumatic events might have triggered the patient’s reaction to distress. However, this differential diagnosis is ruled out because the patient has no symptoms of flashbacks, intrusive distressing memories, or nightmares that support the DSM-5-TR diagnostic criteria (Boelen, 2021). Additionally, the patient has no signs of depressive avoidance of traumatic event triggers.
Reflections:
If I could conduct the patient evaluation session, I would establish the impact of the patient’s suicide attempts on his mental health. I would engage the patient in a pre-and post-trauma experience assessment to identify his perception of his upbringing and childhood. This approach is necessary to identify whether the patient’s background contributes to his irrational behaviors and mental impairment. Additionally, I would engage the patient’s family and partner to establish his reaction to distress and coping means. I would interview the patient’s family to identify resources available to support his recovery and educate the family to monitor his mental health progress.
Case Formulation and Treatment Plan:
The patient has a history of depression and treatment deferment. Therefore, it is necessary to focus on restoring good mental health through psychotherapy to reduce the risk of depression exacerbation. I would recommend the patient to a psychotherapist to aid with coping with distress (Gartlehner et al., 2021). I can collaborate with the patient’s primary care physician to provide emotional, psychological, and social support. I would also recommend the patient for cognitive group therapy. According to Gartlehner et al. (2021), this intervention can help the patient build good interpersonal relations and maintain family ties. The patient can also learn how to overcome suicide ideation and avoid self-harm and injury. I would also recommend the patient to psychiatric management, focusing on symptom-targeted pharmacotherapy (Gartlehner et al., 2021). This intervention can help the patient overcome his symptoms and control his moods and emotions.
Additionally, I can recommend the patient to a social support group. This intervention aims to help the patient deal with childhood traumas and abandonment. The patient can learn how to cope with distress and control anger from other people’s experiences. Additionally, the patient can gain hope in life, avoid suicide attempts, regain self-worth and build self-esteem. Finally, I would prescribe fluvoxamine 50mg per day to help minimize the symptoms.
I would involve the patient’s mother in the planning and implementation of the proposed care plan to improve patient adherence to medication and psychotherapy. Additionally, I can follow up with the patient to monitor his progress. These interventions can help the patient cope with the debilitating symptoms and help his family support him during recovery.
References
Boelen, P. A. (2021). Symptoms of prolonged grief disorder as per DSM-5-TR, post-traumatic stress, and depression: Latent classes and correlations with anxious and depressive avoidance.
Psychiatry Research,
302, 114033.
https://doi.org/10.1016/j.psychres.2021.114033
Gartlehner, G., Crotty, K., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., … & Viswanathan, M. (2021). Pharmacological treatments for borderline personality disorder: A systematic review and meta-analysis.
CNS drugs,
35(10), 1053-1067. doi.org/10.1007/s40263-021- 00855-4
National Institute of Mental Health. (2021). Depression.
https://www.nimh.nih.gov/health/publications/depression#:~:text=To%20be%20diagnose d%20with%20depression,be%20irritable%20rather%20than%20sad
National Institute of Mental Health. (2022, April). Borderline Personality Disorder.
https://www.nimh.nih.gov/health/topics/borderline-personality-disorder
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013).
Am Psychiatric Assoc, 21, 591-643.
© 2021 Walden University Page 1 of 3
RUBRIC
The goal is for the discussion forum to function as robust clinical conferences on the patients. Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.
Questions for the third presentations
1.
What additional nonpharmacological recommendations would you have for a patient suffering from major depressive disorder and or generalized anxiety disorder?
2. Do you agree with my preceptor’s recommendation to change his medication from Zoloft to Effexor? What other medications would you have considered prior to starting Effexor after the failed trial of Zoloft?
3. For patients suffering from major depressive disorder, how would your treatment plan differentiate from an adolescent to an adult?
4. What resources are available in your area to assist patients that are suffering from suicidal ideation or an exacerbation of their depressive symptoms?
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