Week 4: Focused SOAP Note and Patient Case Presentation
\nCollege of Nursing-PMHNP, Walden University
\nNRNP 6665: PMHNP Care Across the Lifespan 1
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\nIntroduction
\nAn individual’s psychiatric examination should be complete and integrated.
\ncrucial in the development of a correct psychiatric diagnosis Facts must be gathered from
\nnumerous sources without bias in order to receive reliable knowledge. The goal of this
\nassignment is to gain an understanding of important questions to ask during an assessment and
\nhow to effectively assess and diagnose a mood disorder based on information acquired from the
\npatient and objective information obtained during an interview by the PMHNP. After
\ninterviewing the patient, the assessment was noted, and three differential diagnoses were
\ndeveloped based on the information gathered during the interview session. A PMHNP was
\nreferred to a 26-year-old White female patient for treatment and continued management of her
\nmental health problem.
\nCC: \u201cI have a history of taking medications and stopping them; I think the medication squashes
\nwho I am”.
\nHPI: J.P a 26-year-old White female who came in for medication management. Patient
\nis currently taking Zoloft which she complains made her high when she is creative and while
\nsleeping her mind will be racing. She also takes Risperidone which made her gain weight. Takes
\nSeroquel which made her gain weight as well, Klonopin, she complained it slowed her down.
\nBecause of the above listed discomfort and side effects patient listed, patient stopped taking the
\nmedication.
\nSubstance History or Current use: Nicotine: smoke about a pack cigarette a day and will
\nnot quit. Alcohol: admits to drinking alcohol but that was 19 years ago. Used marijuana some
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\nyears ago and got paranoid, stopped smoking it. Cocaine and other stimulants: denies use.
\nCaffeine: denies. Sedatives: Denies. Denies use of mushrooms. Denies use of pain pills or street
\ndrugs. Denies use of any type of ecstasy drugs.
\nFamily Psychiatric: Mother had bipolar, Father was arrested and had jail time in prison due to
\ndrugs for 10 years now. Brother has schizophrenia but never went to hospital for treatment. No
\nfamily history of suicide. Patient admits that she tried to kill herself once in the past but I won’t
\ndo it again.
\nPsycho-social History: Lives: lives with her mother and sometimes her boyfriend. Goes over to
\nher mother if her boyfriend\u2019s gets mad at her for sleeping around. Work: employed; works with
\naunt’s bookstore. Misses work when she is feeling low. Education: in school for cosmetology to
\ndo make up for movie stars. Fun activities: writing her life story, paints Picasso. Arrest: police
\npicked patient up and took her the hospital that she was found dancing naked. Trauma: Father
\nwas pretty tough and yelled at them a lot. Raised by mother and older brother.
\nHospitalization: Patient have been admitted four times. Admitted for suicide
\nideation: overdosed with Benadryl in 2017. When patient was a teenager, went for some days
\nwithout sleeping. They gave patient some medication in the hospital that she can\u2019t remember the
\nname.
\nPsychiatric History: Depression, Anxiety, Bipolar. Depression: get depressed for about 4 to 5
\ntimes a year; when patient does not have any energy or creativity then patient feels depressed and
\nnot want to do anything. During those episodes, are times when patient does not take her
\nmedication. Patient denies being having anxiety at this time. Denies repetitive episodes or OCD.
\nDenies AVH\/Delusions. Only hallucinates when she is not sleeping well; she hears voice. But
\nnone at this time. Appetite: when creative she is too busy to eat, when she is crashing, she eats a
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\nlot. Bad dreams: denies bad dreams. Sleep: 5 to 6 hours. When creative sleeps for 3 hours a
\nweek. When crashing can sleep for 12 to 16 hours a day.
\nCurrent Medication: Zoloft, Risperidone, Seroquel, Klonopin, pregnancy control pill
\nAllergies: NKDA
\nReproductive History: patient is sexually active. Patient states that she likes to have a lot of
\nsex and it makes her feel high. Takes birth control pill for PCO. Her birth control is regular
\ntype.
\nMedical history: Hypothyroidism, PCO
\nROS:
\nGENERAL: feeling warm, no chills, no fatigue
\nHEENT: Eyes: Vision intact, yellow sclerae. Ears: positive earache, positive hard of hearing,
\nNose: denies runny nose, sneezing, or congestion, Throat: no sore throat.
\nSKIN: Warm to touch, No rash
\nCARDIOVASCULAR: No chest pain, No palpitations, or edema.
\nRESPIRATORY: No shortness of breath, negative for cough or hemoptysis
\nGASTROINTESTINAL: Occasional constipation, No nausea, vomiting, or diarrhea. No
\nabdominal pain, no blood stool
\nGENITOURINARY: denies any problem with urination or bladder
\nNEUROLOGICAL: frequent headache, no syncope, numbness, or tingling in the extremities.
\nMUSCULOSKELETAL: occasional should and back pain, No muscle, joint pain, or stiffness.
\nHEMATOLOGIC: No anemia or bleeding disorder
\nLYMPHATICS: No enlarged nodes.
\nPSYCHIATRIC: a history of bipolar, depression
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\nENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or
\npolydipsia.
\nDiagnostic results: No diagnostic test or labs needed during the session
\nAssessment
\nMental Status Examination
\nJ.P. is orientated four times. During the interview, you must be able to correctly answer
\nquestions, follow orders, and remain alert. She is also nice and neurologically sound. Her mood
\nis balanced but dysthymic. She responds to all questions and goes into great depth when
\nnecessary. Although there were no acute psychosis or mood symptoms, the patient appeared
\nconcerned. Denies any current or previous history of suicide. Denies having any homicidal ideas
\nor hearing voices or thoughts that might cause harm to people. All of your memories are still
\nintact.
\nDiagnostic Impression
\nBipolar Disorder: The following diagnosis is based on the information supplied and is subject
\nto change as new data becomes available during later sessions. Bipolar disorder also known as
\nmanic-depressive illness or manic depression, is a mental condition that causes erratic mood
\nswings, energy, activity levels, focus, and the ability to perform daily chores. People with bipolar
\nillness have times of exceptionally high mood, changes in sleep patterns and activity levels, and
\nuncommon actions, which they don’t always recognize as harmful or undesired. The term “mood
\nepisodes” refers to these separate intervals (Bachem & Casey, 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). To be diagnosed with a
\nbipolar disorder, an individual must meet specific criteria, according to the DSM-5. Within two
\nweeks, the patient must experience 5 or more of the following symptoms: A distinct time of
\nabnormally and persistently high, expansive, or irritable mood, as well as abnormally and
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\npersistently heightened activity or energy, that lasts at least 4 days and is present virtually every
\nday (American Psychiatric Association, 2013). Our patient J.P presented with symptoms and
\nbehavior that correlates with the above listed symptoms: patient states that she get depressed
\nfor about 4 to 5 times a year; when patient does not have any energy or creativity then patient
\nfeels depressed and not want to do anything. During those episodes, are times when patient does
\nnot take her medication. Patient states that she likes to have a lot of sex with different people,
\neven though she has a boyfriend, that it makes her feel high. Patient smoke about a pack cigarette
\na day, said she is planning to quit. Admitted for suicide ideation: overdosed with Benadryl.
\nPatients works in her aunt\u2019s bookstores but can stay away as she likes she does not feel like it.
\nBorderline Personality Disorder: Borderline Personality Disorder is a major mental health
\ncondition with no recognized etiology. Individuals with Borderline Personality Disorder have
\ncontinuous mood swings, self-image issues, impulsive behavior, and trouble relating to others,
\neven animals (Sadock, et al., 2015 – Research Paper Writing Help Service). A pattern of changing moods, self-image, and behavior
\ncharacterizes borderline personality disorder. Impulsive behavior and relationship issues are
\ncommon outcomes of these symptoms. Anger, despair, and anxiety can persist anywhere from a
\nfew hours to days in people with borderline personality disorder. According to the DSM-5, the
\npatient must have experienced these symptoms for at least 6 months: disabling episodes of anger,
\ndepression, and anxiety that last for hours or days, problems controlling anger, difficulty trusting,
\nirrational fear of other people’s intentions, feelings of dissociation, and feelings of emptiness;
\nintense episodes of anger, depression, and anxiety that last for hours or days; problems
\ncontrolling anger, difficulty trusting, irrational fear of other people’s intentions, feelings of
\ndissoci (American Psychiatric Association, 2013). The above-listed symptoms are evident in J.P
\nour patient as evidenced by patient get depressed for about 4 to 5 times a year; when
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\npatient does not have any energy or creativity then patient feels depressed and not want to do
\nanything. During those episodes, are times when patient does not take her medication. Patient
\nstates that she likes to have a lot of sex with different people, even though she has a boyfriend,
\nthat it makes her feel high. Patient smoke about a pack cigarette a day, said she is planning
\nto quit. Admitted for suicide ideation: overdosed with Benadryl. Patients works in her aunt\u2019s
\nbookstores but can stay away as she likes she does not feel like it.
\nGeneralized Anxiety Disorder:
\nReflection
\nCBT treatment recommendation
\nCase Formulation and Treatment Plan
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