NRNP 6665: PMHNP Care Across the Lifespan I
Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders
SOAP NOTE EXAMPLE 1
Subjective:
CC (chief complaint): : “I have a problem in adhering to my medicines and occasionally I feel like quitting them. I don’t really think I need them. I feel like the medicine Squashes me.”
HPI: Petunia Park is a female patient who is 25 years old. She has a history of depression as well as bipolar illness, both of which she controls using medicines. During the visit today, she grouses about how much she wishes she could stop taking her medicines. The patient has expressed prior thoughts of killing themselves by taking their own life. She reports that she has a hard time falling asleep and that she regularly hears voices when she is awake. She considered her lack of sleep to be transitory and gave a rating of 15 to 21 on a Linkert scale that ranged from 0 to 28.
Substance Current Use: Reports alcohol, cigarettes, and marijuana use.
Medical History: Denies any medical history. Reports one hospitalization due to suicide attempt.
- Current Medications: Zoloft 200mg once daily for depression, Seroquel 50mg once daily for bipolar illness, and Risperidone 4mg daily
- Allergies: NKA
- Reproductive Hx: LMP: 21/6/2020, last Pap: normal
ROS:
- GENERAL: Denies weight loss, fever, chills, weakness, or fatigue.
- HEENT: Denies eye pain or vision problems. Denies ear pain or hearing loss. Denies sinus problems or sore throat.
- SKIN: Denies no rash, lessions, or ecchymosis.
- CARDIOVASCULAR: Denies chest pain orheart murmurs or palpitations. No swelling
- RESPIRATORY: Denies shortness of breath or cough. No difficulty in breathing or production of sputum.
- GASTROINTESTINAL: Denies nausea and vomiting, and no diarrhea or blood in the stool.
- GENITOURINARY: Denies abnormal bladder function and emptying.
- NEUROLOGICAL: Denies headaches, dizziness, syncope,or numbness
- MUSCULOSKELETAL: Denies muscle pain or joint pain.
- HEMATOLOGIC: No history of anemia
- LYMPHATICS: Denies enlarged lymph nodes.
- ENDOCRINOLOGIC: reports being treated for hypothyroidism. Denies night sweats, polydipsia or polyuria.
Objective:
Diagnostic results: no laboratory tests done
Assessment:
Mental Status Examination:
Patient is oriented x4 oriented. She is well-dressed, well-groomed and well-nourished. She cooperative as seen through her willingness to respond to questions and has clear and coherent speech. Her memory is intact. No current suicide ideation, delusions but has had auditory hallucinations and suicide attempt in the past. Her throught process is logical and judgment is intact.
Diagnostic Impression:
Bipolar disorder: The mental health condition known as bipolar disorder is characterized by extreme shifts in mood. Patients who suffer from this condition often exhibit aggressive behaviors, a propensity to get quickly sidetracked, rushed thinking, and euphoria (Vieta et al., 2018).
Depression: A low mood, along with other negative emotions such as worthlessness, despair, or guilt, is a hallmark of this mental illness. Additionally, the illness manifests itself in suicidal thoughts, and some patients even go so far as to attempt suicide (Tolentino & Schmidt, 2018).
Hypothyroidism: The main symptoms of this disorder include physiological signs, in addition to symptoms such as feelings of sadness, slow thinking processes, exhaustion, and slow movement (Duntas & Yen, 2019). In addition, there is a shortening of attention span, sleep problems, fatigue, excessive daytime sleepiness, mood disturbance, and psychotic features.
Reflections:
I would look into assessing the patient to establish if or not there are any more causes adding to her symptoms. The present diagnosis is apropriate, and it would make it easy to treat her condition.
Case Formulation and Treatment Plan:
The treatment for bipolar disorder, which is a chronic condition, focuses on relieving the symptoms that the patient is currently experiencing. It has a tremendous impact on the emotional state of a person. I will provide this patient with a prescription for a mood stabilizer of 250 milligrams, such as Depakene, to be taken two times per day. If the symptoms continue for more than four weeks after treatment with mood stabilizers, I will recommend that the patient take the antipsychotic risperidone 4 milligrams orally twice daily.
References
Duntas, L. H., & Yen, P. M. (2019, October 1). Diagnosis and treatment of hypothyroidism in the elderly. Endocrine, Vol. 66, pp. 63–69. https://doi.org/10.1007/s12020-019-02067-9
Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 Criteria and Depression Severity: Implications for Clinical Practice. Frontiers in Psychiatry, 9(OCT), 450. https://doi.org/10.3389/fpsyt.2018.00450
Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., … Grande, I. (2018). Bipolar disorders. Nature Reviews Disease Primers 2018 4:1, 4(1), 1–16. https://doi.org/10.1038/nrdp.2018.8
SOAP NOTE EXAMPLE 2
Subjective:
CC (chief complaint): “I have a history of taking medications and then stopping them. I don’t feel like I need them. The medication squashes who I am.”
HPI: The patient took different medications and had a history of taking and then stopping since they squash who she is and therefore does not need them. Still, they have not effectively managed the clinical symptoms, and she is unwilling to continue with the medication.
Substance Current Use: Currently consumes a cigarette pack every day and has no plans to change her habit. Denies current alcohol or illicit drugs use.
Medical History:
Polycystic ovarian syndrome
Hypothyroidism
- Current Medications: hypothyroidism medication (pt cannot remember the name), oral contraceptive pills.
- Allergies: NKA
- Reproductive Hx: Reports being sexually active, multiple partners. LMP one month ago.
ROS:
- GENERAL: Denies fever, fatigue, chills, or headache.
- HEENT: Denies headache, vision problems, eye pain, hearing changes, or ear pain. Denies nasal problems, sinus pain, dysphagia,or throat problems.
- SKIN: Denies rash, lesions, or itching.
- CARDIOVASCULAR: Denies chest pain, palpitations, or edema
- RESPIRATORY: Denies shortness of breath, cough, or respiratory distress.
- GASTROINTESTINAL: Denies nausea or vomiting, abdominal pain, diarrhea, or constipation.
- GENITOURINARY: Denies hesitancy, pain on urination, hematuria, or incontinence
- NEUROLOGICAL: Denies vertigo, sense of imbalance, or numbness or tingling.
- MUSCULOSKELETAL: Denies mucle pain, back pain, or joint pain.
- HEMATOLOGIC: Denies bleeding, easy brusing, or anemia
- LYMPHATICS: Denies painful or swollen lymph nodes.
- ENDOCRINOLOGIC: Reports having hypothyroidism
Objective:
Diagnostic results: Diagnostic tests not done at this time.
Assessment:
Mental Status Examination: Patient is alert and oriented x4. She is properly attired for the occasion and well-groomed. Her appearance is consistent with the age that she claims to be. Her articulation is appropriate in terms of clarity, suitability of tone and tempo, and coherence. During the course of the interview, she demonstrated excellent communication abilities and responded thoughtfully to each question. Her affect is poised and cheerful at all times. She is in a euthymic mood. She has intact long-term and short-term memory. She makes certain delusional claims, like selling her paintings to Movie stars. Denies having any homicidal or suicidal thoughts or ideas. Denies having visual, auditory, or other types of hallucinations. Because she has bipolar disorder, she has periods of both manic and depressed behavior. Her medical choices and sexual decisions both show that she has poor judgment.
Diagnostic Impression:
Bipolar Disorder, moderate (F31.2)
A mental disease called bipolar disorder is characterized by severe mood fluctuations that may range from manic to depressive episodes. One must have either manic or depressive episodes, together with or without psychosis, in order to meet the DSM-5 criteria for this disease. Individuals who are experiencing a Bipolar episode could exhibit overly verbose speech, a sense of haughtiness, extended periods of sleepiness, and poor vitality. They may also have an exaggerated sense of self-worth, psychomotor restlessness, rapid mental processes, and a propensity toward reckless conduct like irresponsible sexual behaviour or wasteful spending (Bobo,2017). Both drug usage and other health conditions are ruled out as causes of these symptoms. Patient described having racing thoughts and times of “creativity.” She defines these times as high moods when she sleeps 3 hours a day without feeling fatigued. Additionally, she says she has depression episodes from time to time, during which she feels useless, lacks drive, and has low energy.
Attention-Deficit Hyperactivity Disorder (F90.1)
This is a chronic disorder that includes difficulties paying attention, being hyperactive, and acting impulsively. Patients who take it report feeling unable to exert self-control, sitting still, and paying attention to what is going on around them. In order to get a diagnosis of ADHD, individuals need to exhibit symptoms over a period of at least six months. Impairments in academic and social functioning are common in this disorder, as are disruptive tendencies like constant interruptions, a lack of focus, and an inability to remain still for more than a few minutes at a time (Te Meerman et al., 2017). The patient notes that she exhibits behaviors in her relationship that are impulsive and aggressive.
Generalized Anxiety Disorder (F41.1)
The symptoms of generalized anxiety disorder include persistent feelings of being overwhelmed, dread, and concern. Generalized anxiety disorder is a mental health problem. The amount of worry is overwhelming, challenging to manage, and is frequently associated with a wide variety of psychological and physical symptoms that are not particular to any one condition. The DSM-V diagnostic criteria for generalized anxiety disorder include excessive anxiety and concern for at least six months, trouble managing the worrying, and the worry being accompanied with three or more symptoms such as restlessness, sleep disruption, and agitation for at least six months. In addition, the excessive anxiety must have been present for at least six months. The stress caused by GAD may be so severe that it can interfere with a person’s ability to go about their regular life (Iani et al., 2019). During the course of the interview, Ms. P.P. said that there are times when she has trouble falling or staying asleep, as well as times when she sleeps for longer than is required.
Reflections:
The interviewer did a wonderful job of introducing herself and explaining why she wanted to speak with the patient. She prepared the patient on what to anticipate from the appointment and what would happen next. What I found lacking in the clip was Dr. Moore informing the patient of the scope of patient confidentiality. As a professional, one has a legal and ethical duty to discuss the parameters of Confidentiality. At this point, the patient is given all the information she needs to make an educated choice about her therapy, including a breakdown of the various treatment plans and an explanation of the pros and cons of each. There can be no clinical rapport between patient and mental health professional unless the patient is given some say in their care. It is crucial to make sure that the patient is aware of and comfortable with the available therapeutic choices, their potential advantages and dangers, and the required monitoring and follow-up.
Case Formulation and Treatment Plan:
Patient’s recurrent depressive and manic episodes are characteristic with bipolar disorder, the primary diagnosis. The patient claims that she has “creative” bouts of alertness, flight of ideas, impulsive conduct, ideation, delusions, and grandiosity during her manic episodes. She felt hopeless and unmotivated to accomplish anything; she was exhausted all the time and slept for extended stretches of time; she was skipping work; and she was sleeping excessively. The initial and most important step in treating this patient is to start her on a mood stabilizer. The patient claims she cannot remember the names of all of the drugs she has been given in the past. For this reason, it is appropriate for the clinician to ask for the patient’s permission before obtaining information on the patient’s previous medical history and drugs. This will aid in the process of prescribing a new treatment to the patient, one that they are more likely to follow through on and benefit from. Because the patient had not disclosed her current drug regimen, it would be prudent to check for pregnancy and evaluate her liver and kidneys prior to prescribing any new medicine. Since the patient has not indicated either valproic acid or valproate as being among those previously taken, doctors may consider any of these to be a viable alternative. For individuals with bipolar illness, these drugs show promise in the treatment of both acute mania and depressive bouts (Shah et al., 2017). The patient may begin taking Depakote (250 mg P.O. twice day) in addition to the olanzapine (2.5 mg P.O. daily). It is possible to increase the dosage while keeping an eye on any adverse outcomes and serum concentrations.
The non-pharmaceutical therapeutic modalities of psychoeducation and psychotherapy may be utilized in tandem with pharmaceutical interventions. The need of taking medicine as prescribed, the potential for unpleasant effects, the need to make dietary changes, and the potential impact on fertility are all topics that should be covered during patient education. Medical professionals have a duty to inform their pregnant patients of any and all potential drug side effects. Teratogenic drugs, including Depakote, should never be used by a woman who is pregnant or attempting to become pregnant (Sarayani et al., 2022). Psychotherapy has been shown to be effective in reducing the severity of manic episodes and maintaining remission for lengthy periods of time.
References
Bobo, W. V. (2017). The diagnosis and management of bipolar I and II disorders: Clinical practice update. Mayo Clinic Proceedings, 92(10), 1532-1551. https://doi.org/10.1016/j.mayocp.2017.06.022
Iani, L., Quinto, R. M., Lauriola, M., Crosta, M. L., & Pozzi, G. (2019). Psychological well-being and distress in patients with generalized anxiety disorder: The roles of positive and negative functioning. PLOS ONE, 14(11), e0225646. https://doi.org/10.1371/journal.pone.0225646
Sarayani, A., Albogami, Y., Thai, T. N., Smolinski, N. E., Patel, P., Wang, Y., Nduaguba, S., Rasmussen, S. A., & Winterstein, A. G. (2022). Prenatal exposure to teratogenic medications in the era of risk evaluation and mitigation strategies. American Journal of Obstetrics and Gynecology, 227(2), 263.e1-263.e38. https://doi.org/10.1016/j.ajog.2022.01.004
Shah, N., Grover, S., & Rao, G. P. (2017). Clinical practice guidelines for management of bipolar disorder. Indian Journal of Psychiatry, 59(5), S51–S66. https://doi.org/10.4103/0019-5545.196974
Te Meerman, S., Batstra, L., Grietens, H., & Frances, A. (2017). ADHD: A critical update for educational professionals. International Journal of Qualitative Studies on Health and Well-being, 12(sup1), 1298267. https://doi.org/10.1080/17482631.2017.1298267