Week Four: Targeted SOAP Be aware and Affected person Case Presentation
Faculty of Nursing-PMHNP, Walden College
NRNP 6665: PMHNP Care Throughout the Lifespan 1
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Introduction
A person’s psychiatric examination needs to be full and built-in.
essential within the growth of an accurate psychiatric analysis Information should be gathered from
quite a few sources with out bias so as to obtain dependable data. The purpose of this
project is to achieve an understanding of vital inquiries to ask throughout an Assessment and
the best way to successfully assess and diagnose a temper dysfunction primarily based on info acquired from the
affected person and goal info obtained throughout an interview by the PMHNP. After
interviewing the affected person, the Assessment was famous, and three differential diagnoses have been
developed primarily based on the data gathered in the course of the interview session. A PMHNP was
referred to a 26-year-old White feminine affected person for therapy and continued administration of her
psychological well being downside.
CC: “I’ve a historical past of taking drugs and stopping them; I believe the remedy squashes
who I’m”.
HPI: J.P a 26-year-old White feminine who got here in for remedy administration. Affected person
is at present taking Zoloft which she complains made her excessive when she is inventive and whereas
sleeping her thoughts can be racing. She additionally takes Risperidone which made her acquire weight. Takes
Seroquel which made her acquire weight as nicely, Klonopin, she complained it slowed her down.
Due to the above listed discomfort and uncomfortable side effects affected person listed, affected person stopped taking the
remedy.
Substance Historical past or Present use: Nicotine: smoke a couple of pack cigarette a day and can
not give up. Alcohol: admits to ingesting alcohol however that was 19 years in the past. Used marijuana some
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years in the past and bought paranoid, stopped smoking it. Cocaine and different stimulants: denies use.
Caffeine: denies. Sedatives: Denies. Denies use of mushrooms. Denies use of ache drugs or road
medicine. Denies use of any sort of ecstasy medicine.
Household Psychiatric: Mom had bipolar, Father was arrested and had jail time in jail as a consequence of
medicine for 10 years now. Brother has schizophrenia however by no means went to hospital for therapy. No
household historical past of suicide. Affected person admits that she tried to kill herself as soon as prior to now however I will not
do it once more.
Psycho-social Historical past: Lives: lives along with her mom and typically her boyfriend. Goes over to
her mom if her boyfriend’s will get mad at her for sleeping round. Work: employed; works with
aunt’s bookstore. Misses work when she is feeling low. Training: in class for cosmetology to
do make up for film stars. Enjoyable actions: writing her life story, paints Picasso. Arrest: police
picked affected person up and took her the hospital that she was discovered dancing bare. Trauma: Father
was fairly robust and yelled at them quite a bit. Raised by mom and older brother.
Hospitalization: Affected person have been admitted 4 occasions. Admitted for suicide
ideation: overdosed with Benadryl in 2017. When affected person was a young person, went for some days
with out sleeping. They gave affected person some remedy within the hospital that she will’t keep in mind the
title.
Psychiatric Historical past: Despair, Anxiousness, Bipolar. Despair: get depressed for about Four to five
occasions a yr; when affected person doesn’t have any vitality or creativity then affected person feels depressed and
not need to do something. Throughout these episodes, are occasions when affected person doesn’t take her
remedy. Affected person denies being having nervousness presently. Denies repetitive episodes or OCD.
Denies AVH/Delusions. Solely hallucinates when she is just not sleeping nicely; she hears voice. However
none presently. Urge for food: when inventive she is simply too busy to eat, when she is crashing, she eats a
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lot. Dangerous desires: denies dangerous desires. Sleep: 5 to six hours. When inventive sleeps for three hours a
week. When crashing can sleep for 12 to 16 hours a day.
Present Treatment: Zoloft, Risperidone, Seroquel, Klonopin, being pregnant management capsule
Allergy symptoms: NKDA
Reproductive Historical past: affected person is sexually energetic. Affected person states that she likes to have quite a lot of
intercourse and it makes her really feel excessive. Takes contraception capsule for PCO. Her contraception is common
sort.
Medical historical past: Hypothyroidism, PCO
ROS:
GENERAL: feeling heat, no chills, no fatigue
HEENT: Eyes: Imaginative and prescient intact, yellow sclerae. Ears: constructive earache, constructive laborious of listening to,
Nostril: denies runny nostril, sneezing, or congestion, Throat: no sore throat.
SKIN: Heat to the touch, No rash
CARDIOVASCULAR: No chest ache, No palpitations, or edema.
RESPIRATORY: No shortness of breath, unfavourable for cough or hemoptysis
GASTROINTESTINAL: Occasional constipation, No nausea, vomiting, or diarrhea. No
stomach ache, no blood stool
GENITOURINARY: denies any downside with urination or bladder
NEUROLOGICAL: frequent headache, no syncope, numbness, or tingling within the extremities.
MUSCULOSKELETAL: occasional ought to and again ache, No muscle, joint ache, or stiffness.
HEMATOLOGIC: No anemia or bleeding dysfunction
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: a historical past of bipolar, melancholy
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ENDOCRINOLOGIC: No reviews of sweating, chilly, or warmth intolerance. No polyuria or
polydipsia.
Diagnostic outcomes: No diagnostic check or labs wanted in the course of the session
Assessment
Psychological Standing Examination
J.P. is oriented 4 occasions. Through the interview, you should have the ability to accurately reply
questions, comply with orders, and stay alert. She can also be good and neurologically sound. Her temper
is balanced however dysthymic. She responds to all questions and goes into nice depth when
essential. Though there have been no acute psychosis or temper signs, the affected person appeared
involved. Denies any present or earlier historical past of suicide. Denies having any homicidal concepts
or listening to voices or ideas which may trigger hurt to folks. All your recollections are nonetheless
intact.
Diagnostic Impression
Bipolar Dysfunction: The next analysis relies on the data equipped and is topic
to vary as new knowledge turns into out there throughout later classes. Bipolar dysfunction also called
manic-depressive sickness or manic melancholy, is a psychological situation that causes erratic temper
swings, vitality, exercise ranges, focus, and the flexibility to carry out each day chores. Individuals with bipolar
sickness have occasions of exceptionally excessive temper, adjustments in sleep patterns and exercise ranges, and
unusual actions, which they do not all the time acknowledge as dangerous or undesired. The time period “temper
episodes” refers to those separate intervals (Bachem & Casey, 2018). To be recognized with a
bipolar dysfunction, a person should meet particular standards, in response to the DSM-5. Inside two
weeks, the affected person should expertise 5 or extra of the next signs: A definite time of
abnormally and persistently excessive, expansive, or irritable temper, in addition to abnormally and
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persistently heightened exercise or vitality, that lasts a minimum of Four days and is current nearly each
day (American Psychiatric Affiliation, 2013). Our affected person J.P introduced with signs and
habits that correlates with the above listed signs: affected person states that she get depressed
for about Four to five occasions a yr; when affected person doesn’t have any vitality or creativity then affected person
feels depressed and never need to do something. Throughout these episodes, are occasions when affected person does
not take her remedy. Affected person states that she likes to have quite a lot of intercourse with completely different folks,
though she has a boyfriend, that it makes her really feel excessive. Affected person smoke a couple of pack cigarette
a day, mentioned she is planning to give up. Admitted for suicide ideation: overdosed with Benadryl.
Sufferers works in her aunt’s bookstores however can keep away as she likes she doesn’t really feel prefer it.
Borderline Persona Dysfunction: Borderline Persona Dysfunction is a serious psychological well being
situation with no acknowledged etiology. People with Borderline Persona Dysfunction have
steady temper swings, self-image points, impulsive habits, and hassle regarding others,
even animals (Sadock, et al., 2015). A sample of adjusting moods, self-image, and habits
characterizes borderline persona dysfunction. Impulsive habits and relationship points are
widespread outcomes of those signs. Anger, despair, and nervousness can persist anyplace from a
few hours to days in folks with borderline persona dysfunction. In response to the DSM-5, the
affected person should have skilled these signs for a minimum of 6 months: disabling episodes of anger,
melancholy, and nervousness that final for hours or days, issues controlling anger, problem trusting,
irrational worry of different folks’s intentions, emotions of dissociation, and emotions of vacancy;
intense episodes of anger, melancholy, and nervousness that final for hours or days; issues
controlling anger, problem trusting, irrational worry of different folks’s intentions, emotions of
dissoci (American Psychiatric Affiliation, 2013). The above-listed signs are evident in J.P
our affected person as evidenced by affected person get depressed for about Four to five occasions a yr; when
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affected person doesn’t have any vitality or creativity then affected person feels depressed and never need to do
something. Throughout these episodes, are occasions when affected person doesn’t take her remedy. Affected person
states that she likes to have quite a lot of intercourse with completely different folks, though she has a boyfriend,
that it makes her really feel excessive. Affected person smoke a couple of pack cigarette a day, mentioned she is planning
to give up. Admitted for suicide ideation: overdosed with Benadryl. Sufferers works in her aunt’s
bookstores however can keep away as she likes she doesn’t really feel prefer it.
Generalized Anxiousness Dysfunction:
Reflection
CBT therapy suggestion
Case Formulation and Remedy Plan
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