NRNP Focused SOAP Note

NRNP/PRAC & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint):

The client is a 14-year old white female who is brought by her parents for refusing to eat, leading to generalized weakness, severe weight loss, and amenorrhea for four months. The parents are worried because the client has had a regular 26-28 day menstruation cycle since she began menarche aged 12. They fear that she could be pregnant although three tests carried out at home have all been negative.

HPI

The client’s parents report that she has been dieting since seven months prior to the visit and that the condition began when her friends teased her about her greedy appetite and plumpness. As a result, she had stared restricting her food intake, engaging routinely in excessive exercises, and avoiding food high in fat. She frequently misses breakfast and lunch, and during dinner, she secretly puts food in a plastic bag and throws it in the dustbin. The client denies inducing purging or vomiting, but she perceives herself as ‘fat’. She is unhappy with her self image and believes that she is not pretty. The client is the oldest of two siblings and describes her parents as overprotective and strict. She feels that her father is excessively controlling and never allows her to make independent decisions. She reports being unable to be her real self as she is forced to live according to her father’s wishes. She admits having difficulty communicating with her younger sister and father, but believes that her mother understands her. Her parents describe her as a perfectionist and a lady obsessed with punctuality and cleanliness. Academically, she is above average and the family history is not indicative of mental illness or eating disorders. A few weeks before the visit, the client experienced epigastric pain that was accompanied by vomiting, joint aches, headaches, and severe fatigue. Her PCP prescribed antiemetics and multivitamins that helped to improve symptoms. The client denies having a boyfriend or involvement in sexual activity.

Substance Current Use:

Medical History:

· Current Medications: None

· Allergies: No Known Allergies

· Reproductive Hx: LMP was four months ago

ROS:

· GENERAL: The client denies chills and fever, although clinical tests show low blood pressure (hypotension) and bradycardia. Clinical examination reveals a thin girl with a height of 1.47m, weight of 28kg, and BMI of 13kg/m3, which reflects a 13 percent deficit in weight for her height.

· HEENT: Eyes: No Visual Loss, blurred vision, double vision, or yellow sclerae; Ears, Nose and Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat

· SKIN: No itching or rash, although skin was generally dry

· CARDIOVASCULAR: No chest tightness, palpitations or edema

· RESPIRATORY: No shortness of breath, cough or sputum

· GASTROINTESTINAL: no stomach cramps, indigestion, constipation, or heartburn

· GENITOURINARY: No burning on urination, hesitancy, or odd color

· NEUROLOGICAL: Occasional headaches and dizziness, but no change in bladder or bowel control.

· MUSCULOSKELETAL: Generalized muscle weakness

· HEMATOLOGIC: No signs of bleeding, anemia or bruises

· LYMPHATICS: Nodes are of normal size

· ENDOCRINOLOGIC: client denies experiencing cold, profuse sweating, or heat intolerance. No polyuria or polydipsia .

Objective:

Diagnostic results:

An electrocardiogram (EKG) test and chest x-rays were ordered to rule out cardiac conditions as potential causes of the client’s hypotension (Khairani et al., 2011). The clinician additionally ordered a complete blood count (CBC) to exclude medical conditions such as anemia and hyperthyroidism, which have similar presentations and could also account for amenorrhea and the frequent headaches and dizziness (Khairani et al., 2011). Results of the blood investigation were within normal limits. A urine pregnancy test was also ordered to check for pregnancy. The test showed a negative result. A pelvic ultrasound ordered to check for abnormalities that could be causing amenorrhea showed no abnormalities in the client’s pelvic organs. A gastroscopy was ordered to rule out abnormalities in the digestive tract such as malabsorption as potential causes of the client’s vomiting and nausea (Khairani et al., 2011).

Assessment:

Mental Status Examination:

The client is a white female who looks her stated age, although she appears shorter and smaller than her matching peers. She is alert and attentive throughout the clinical interview, and is oriented to time, place, person, and event. Her speech is coherent and rational and does not reveal hallucinations. The client displays a depressed mood but denies illusions and paranoid thought processes and suicidal/homicidal ideation. Her judgment and insight are both grossly intact. However, she expresses strong denial of her body appearance and insists that her body shape is normal.

Diagnostic Impression

Three differential diagnoses could be obtained from the subjective and objective information: bulimia nervosa, avoidant/restrictive food intake disorder, and anorexia nervosa. .

Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating (criterion A) that are followed by inappropriate compensatory behaviors to prevent weight gain such as excessive exercise, diuretics, and self-induced vomiting (criterion B) (APA 2013). Patients with bulimia nervosa are also excessively concerned about their body shape and weight (criterion C). The presenting client is overly concerned about her body shape and keeps referring to herself as ‘fat’ despite the low BMI of 13kg/m3 (Criterion C). Although the client admits to taking part in excessive exercises, she denies inducing vomiting and there is no evidence of engagement in binge eating as required by criterion A. As such, bulimia nervosa is the least likely of the three diagnoses.

The APA (2013) defines avoidant/restrictive food intake disorder as an eating or feeding disturbance as manifested by persistent failure to meet nutritional/energy needs associated with one of the following: a) significant weight loss, b) significant nutritional deficiency, c) dependence on nutritional supplements, and d) significant interference with psychosocial functioning. The disturbance is not better explained by cultural practices or lack of available food, and is not attributable to a medical condition (APA, 2013). The main diagnostic feature is eating or feeding disturbance, which the client demonstrates by skipping meals and avoiding certain foods, resulting in a low body weight and BMI of 13kg/m3. However, criterion C of the DSM-V manual states that the eating feeding disturbance is not better explained by excessive concern about one’s body shape and weight (APA, 2013). The presenting client is overly concerned about her body shape – she perceives herself as ‘fat’ and unattractive, and engages in food avoidance as a way of addressing these concerns. The marked concern about body shape makes it unlikely that the client has avoidant/restrictive food intake disorder.

The most likely diagnosis for the presenting client is anorexia nervosa. Anorexia nervosa is characterized by: a) restriction of energy intake leading to a significantly lower body weight than would be considered normal, b) intense fear of becoming fat or gaining weight and persistent engagement in activities that curtail weight gain, and c) undue influence on body weight and shape on self-evaluation and lack of recognition of the seriousness of the low body weight (APA, 2013). The presenting client reports a low BMI of 13kg/m3, which reflects a 13 percent deficit in weight for his height (criterion A). She is excessively concerned about gaining weight and engages in excessive exercises, and food avoidance to prevent the same (criterion B). Finally, the client does not recognize the seriousness of her condition and insists hat her body shape is normal (criterion C). The most likely diagnosis from the client’s sympoms is restricting type extreme anorexia nervosa (F50.0). .

Reflections:

According to the APA (2013), most patients with anorexia nervosa exhibit depressive symptoms such as insomnia, irritability, loss of interest in significant activities, a depressed mood, and irritability. Studies have shown that depression is the most common comorbid diagnosis among patients with eating disorders, with a prevalence rate of 40 percent among anorexia nervosa patients and 50 percent among bulimia nervosa patients (Yan et al., 2019). This information indicates that there may have been a need to investigate the client’s depressed mood further by testing for the presence of major depressive disorder.

Case Formulation and Treatment Plan: 

Initiation Of:

The goal of treatment is to promote weight gain and healthy eating as well as psychological recovery (Resmark et al., 2019). The patient was admitted into the clinic for the extremely low BMI, and nasogasric refeeding was initiated for a week until oral feeding could be established. To treat the patient’s depressive symptoms and obsessions related to food and cleanliness, the clinician began SSRI treatment, prescribing 20mg of Fluoxetine daily for an initial period of 14 days. The Food and Drug Administration (FDA) has not approved any medication for the treatment of anorexia nervosa. However, Fluoxetine is the most studied SSRI in the treatment of eating disorders and is approved for the treatment of bulimia (FDA, 2014). Fluoxetine and Olanzapine in combination is FDA-approved for the treatment of depressive symptoms associated with bipolar I disorder and schizophrenia (FDA, 2014). For this reason, the clinician additionally prescribed a 5mg daily dosage of Olanzapine (once daily at night) to resolve the client’s distorted thoughts about her body image.

In addition to pharmacotherapy, the clinician initiated cognitive-behavioral therapy to help the client correct the distorted thoughts about her body image and improve her eating habits. Motivational enhancement therapy was recommended to build the client’s self-esteem and motivation for recovery (Ziser, 2021). As the client is a minor, the clinician found it prudent to initiate family interventions that focused on instilling good parenting skills and good eating behaviors. Finally, the client was referred to a dietician for education on how to eat and proper weight-management in line with the set target of gaining 0.5 to 1 kg of weight weekly.

Risks and Benefits of Medication

SSRIs have been associated with a heightened risk of suicidal thoughts among chidren and adolescents (Gordon & Melvin, 2014). This calls for continuous monitoring for changes in thought patterns and proper management to minimize the risk of overdose (Gordon & Melvin, 2014). Generally, however, Fluoxetine has been shown to have a lower risk of suicidal thoughts in pediatric patients as compared to other SSRIs (Gordon & Melvin, 2014). At the same time, Olanzapine has been associated with a high risk of orthostatic hypotension, particularly during initial dose titration (FDA 2014). The client’s bradycardia poses as a risk factor in this case, necessitating proper clinical monitoring for cardiovascular changes (FDA, 2014). When used as prescribed, however, the combination treatment is expected to correct distorted thoughts about body shape in 4 to 6 weeks (FDA, 2014).