Psychiatric Evaluation Comprehensive Focused SOAP

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 presents accompanied by her mother. The chief complaint, as reported by the mother, is that the client’s ‘meds do not seem to be working’. Her grades have been on a consistent downward trend, from As, to Bs, and currently Ds. Conflicts with her sister and mother at home have escalated to the point that her mother describes her as ‘mean’ and ‘nasty’, and she has lost many of her long-standing friends. The client, on her part, says she has no particular complaints and that her mother is exaggerating.

HPI: The client is a 15-year-old white female who is referred by her PCP due to worsening difficulties at school and at home. The client first saw a psychiatrist at the age of 7, when she was evaluated for attention-deficit hyperactivity disorder (ADHD) because of instractibility, impulsivity, and restlessness. After a series of failed behavioral interventions, the client was placed on Methylphenidate-based medication at the age of 8. For the next six years, her social life and scores in school improved, and she was pretty much like ay other kid her age as long as she took her medication. Over the past year, however, the client has stopped being a bubbly teenager and is moody most of the time. She spends days by herself, locked up in her room, and hardly speaks to anyone. During these days, she is uninterested in everything, is constantly complaining that her family and friends do not like her, and sleeps most of the day. Her mother reports that for a week or two, she would be ‘bubbly’, laugh at ‘anything’ and enthusiastically help with the house chores. Then she would again sink into a week or so of persistent sadness and irritability, where she is constantly yelling at her sister and mother to the point that everyone is ‘walking on eggshells’.

At around age 14, her therapist increased her dosage of ADHD medication. The client’s family history is pertinent of bipolar disorder or manic depressive illness, with the mother indicating that the client’s father, whom she has never met, was treated with lithium when they were together.

Substance Current Use: The client denies use of any illicit substances or alcohol

Medical History:

· Current Medications: Concerta 36mg once daily. Client denies taking any OTC drugs or any medication other than her ADHD medication.

· Allergies: No known allergies

· Reproductive Hx: Client denies contraceptive use or engagement in any form of sexual activity. Client claims to be on the second day of her periods.

ROS:

· GENERAL: Denies chills, fever, weight loss, or recent illnesses

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

· SKIN: No itching or rash

· CARDIOVASCULAR: No chest pain or discomfort; paltpitations or edema

· RESPIRATORY: No cough, sputum, or shortness of breath

· GASTROINTESTINAL: No abdominal pain or blood, No nausea, vomiting, diarrhea, or anorexia

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

· NEUROLOGICAL: Slight headache from time to time, dizziness, ataxia, syncope, or numbness/tingling in the extremities, no changes in bladder or bowel control

· MUSCULOSKELETAL: No joint pain, back pain, muscle pain, or stiffness

· HEMATOLOGIC: No signs of bleeding, anemia, or bruises

· LYMPHATICS: Nodes are of normal size and client has no history of splenectomy

· ENDOCRINOLOGIC: Client denies experiencing cold, profuse sweating or heat intolerance. No polydysmia or polyuria.

Objective:

Diagnostic results: In conjunction with the physical examination, the clinician ordered a complete blood count to exclude anemia or infection as potential causes of depressive symptoms (Culpepper, 2014). Fasting glucose and lipid assessments were deemed prudent to establish the presence of hyperlidemia or diabetes, and checking baseline values before commencing treatment (Culpepper, 2014). A CT scan was ordered to exclude an organic etiology for mood symptoms such as multiple sclerosis or a brain tumor (Brunkhorst-Kanaan et al., 2020). All tests yielded normal results, ruling out the likelihood of anemia, blood infection, hyperlidemia, diabetes, or brain abnormalities.

Assessment:

Mental Status Examination: The client is a 15-year-old female of average weight and height. She presents dressed appropriately, with hair neatly pulled back. She is oriented to person and place, and thought processes are coherent and goal-directed. She appears sad and weary throughout the interview, with some affective constriction. There is no evidence of abnormal motor activity, and her speech is clear and coherent, with normal tone and volume. The client denies experiencing halluciations, psychotic symptoms, and suicidal/homicidal thoughts. Her judgment and insight are intact. On examination alone, she expresses that she hates that she feels depressed one day, hilarious the next, and she cannot tell how she will be feeling tomorrow.

Diagnostic Impression: Three differential diagnoses could be obtained from the subjective and objective information: bipolar disorder, ADHD (predominantly inattentive presentation) and Major depressive disorder. The client’s symptoms align with major depressive disorder, in that she exhibits a depressed/irritable mood most of the day, has a lack of interest in activities, hypersomnia, inability to think or concentrate leading to declining academic performance, and feelings of worthlessness. However, a major depressive disorder diagnosis would not explain the alternating depressive and hypomanic episodes that the client experiences. A persistent depressive depressive disorder diagnosis may be likely given that the symptoms have been experienced for over 1 year. However, one of the requirements for persistent depressive disorder is that there should never have been a hypomanic or manic episode (APA, 2013). As such, depressive disorder is the most unlikely of the diferential diagnoses.

ADHD is characterized by impulsive behavior, hyperactivity and poor judgment that can overlap with symptoms of bipolar disorder (Culpepper, 2014). Inattention in ADHD manifests as lacking persistence, wandering off task, being disorganized, lack of comprehension, and difficulty sustaining focus when such is not due to a lack of comperehension or defiance (APA 2013). An associated feature of ADHD is impaired academic or work behavior, which the client exhibits (APA, 2013). Further, the client meets the requirements that the disorder be present in more than one setting, in this case home and school, and that symptoms begin prior to age 12.

The client’s symptoms meet the criteria for bipolar II disorder, characterized by alternating periods of hypomania lasting at least 4 days, and major depressive episodes (APA, 2013). During the hypomanic episode, the client exhibits inflated self-esteem, increase in goal-directed activity, increased energy levels, and is more talkative than usual. During the depressive phase, however, the client shows symptoms of major depressive disorder, including irritability, loss of interest, hypersomnia, diminished ability to concentrate, and feelings of worthlesness over a period of several weeks (APA, 2013). The client has had ADHD since she was 7, and with a family history of bipolar disorder, the most likely diagnosis is bipolar II disorder co-occurring with ADHD. According to Culpepper (2014), symptoms of ADHD and bipolar disorder commonly co-occur.

Reflections:

Mood stabilizers such as lithium are the first-line treatment for bipolar disorder. The FDA approves the use of lithium for the treatment of bipolar I disorder, although the drug is increasingly used in the treatment of bipolar II disorder as well. Further, lithium use in pediataric patients is associated with more adverse effects than with adult patients (FDA, 2018). Lithium has been shown to have serious effects with prolonged use, upto and including renal dysfunction. Given the client’s young age, the risk may be significant, and it may be prudent to ensure that the client adequately understands the risks involved and the need to ensure strict adherence.

Case Formulation and Treatment Plan: 

Initiation Of: Mood stabilizers are the first-line treatment for bipolar disorder. For this reason, the clinician prescribed lithium carbonate tablets or capsules at a starting dose of 300mg three times daily, to be titrated upwards to 600mg after four weeks.

Additionally, the therapist initiated cognitive-behavioral therapy as a form of maintenance treatment – clinical trials have shown that pharmacotherapy combined with CBT is more effective than the former alone in improving depressive symptoms, reducing mania severity, improving psychosocial functioning, and lowering the relapse rate (Chiang et al., 2017).

Client was encouraged to continue the current dosage of Concerta 36mg once daily for a further four weeks

Risk and Benefits of Medication: The client was educated on the adverse effects of Lithium use on pediatric patients aged between 7 and 17, including the risk of nausea or vomiting, fatigue, polyuria, polydipsia, decreased appetite, nervous system disorders, and skin/subcutaneous issue disorders (FDA, 2018). The client is to call the clinician if they experience any of these adverse effects for relevant action. Further, lithium has been shown to cause decreased fetal weight, increased skeletal abnormalities, cleft palate, and cardiovascular malformnations to the fetus when administered during pregnancy (FDA, 2018). In this regard, the client was advised to immediately notify the clinician in case she falls pregnant .

The client was advised not to stop taking the medication abruptly as this increases the risk of mood instability and a relapse of mania. She was also taught that medication adherence is key because bipolar disorder, if left untreated, increases the risk of suicide or homicidal actions. At the same time, overdosing or failure to take the medication as prescribed could lead to lithium toxicity, whose symptoms include increased reflexes, trouyble walking, and kidney problems (FDA, 2018).