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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