Week Seven: SOAP Note one
Taylor Riggins, BSN, RN
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
Subjective: CC (chief complaint): Patient will not talk throughout the assessment. Guardians (mother and father) state
We are here to help her feel better.
HPI: D.H. is a 10-year-old Caucasian female that presents for evaluation and medication. She is currently getting Prozac from her pediatrician, but the parents have not noticed any changes. Parents currently take her to therapy and her therapist suggested that she get evaluated by this practitioner.
She has experienced bullying at school and is getting called ugly and œfat. This has caused her distress to where she has lost a significant amount of weight (97lbs to 68lbs) over the past year from refusing to eat. Parents state that she will not eat any meals. They have tried different options, but she refuses anything other than a protein shake. She appears malnourished today. She struggles with her parents leaving her. She lost her grandfather that she was very close to and that was traumatizing for her. Both of her siblings are leaving this fall for college and her parents think that she is going to experience even more loss. We discussed how Prozac takes 4-6 weeks for therapeutic levels.
Her primary care doctor put her on Prozac to help her gain weight so that she does not have to be hospitalized for failure to thrive, but they have not seen any changes. Parents report that she will curl up in a ball when she is uncomfortable or nervous. She does this throughout the meeting and will tuck her head between her knees to hide her face. Family was educated on high calorie meals and not forcing intake. They report that she plays softball but has no energy to complete a full practice.
Reports that she is withdrawn and won’t go into town for shopping or eating from fear of seeing peers. She gets home from school and goes straight to her room. Parents report that she takes things very personally and is very emotional. Currently in therapy. Reports that she wakes up during the night frequently. She still sleeps on her parent’s floor. Reports of night terrors that are like the Roblox game. Patient’s BMI is 14, so she one point above underweight for her age and height.
- Substance Current Use: Denies any drug, alcohol or tobacco use currently or in the past.
- Medical History: asthma- takes Flovent, Singulair, and breathing treatments (hospitalized at 2-years-old for allergies)
- Current Medications: asthma, flovent, proair inhaler, and nebulizer treatments
- Prozac liquid suspension take 2.5mls (10mg) by mouth daily
- Allergies: seasonal; NKDA
- Reproductive Hx: Has not started her menses. Not sexually active
- Social history- 21-year-old sibling, 2 18-year-old siblings, mother and father live in the home. Born in Topeka, KS. Hit milestones appropriately. Currently in 4th grade and makes As and Bs. Has an IEP for reading and math. Wants to be a firefighter when she grows up.
- Family psychiatric history: mother-anxiety/depression (takes Paxil CR 75mg); father- undiagnosed PTSD
- Surgical history- tonsil and adenoid removal at age 5
ROS:
- GENERAL: Significant weight loss of almost 30lbs in the past year. No fever, chills or weakness. Fatigue noted from decreased caloric intake.
- HEENT: Eyes: no visual disturbances; Ears, nose and throat: No hearing loss, congestion, runny nose, or sore throat
- SKIN: No rash or itching
- CARDIOVASCULAR: No chest pain, palpitations or edema noted
- RESPIRATORY: No shortness of breath, cough or sputum. Patient does have asthma that flares up during season changes
- GASTROINTESTINAL: anorexia noted; no nausea, vomiting, or diarrhea noted. No abdominal pain or blood. Patient has a bowel movement every 3-4 days as baseline
- GENITOURINARY: No burning, itching, frequency or urgency. No abnormal color or smell to urine
- NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in extremities. No change in bowel control.
- MUSCULOSKELETAL: No muscle or joint pain or stiffness
- HEMATOLOGIC: No anemia, bleeding or bruising
- LYMPHATICS: No enlarged lymph nodes. No history of splenectomy.
- ENDOCRINOLOGIC: No reports of sweating or cold or heat intolerance
Objective:
Diagnostic results: height, weight and BMI were calculated in office. Pediatrician had medically cleared any medical causes of the condition prior to assessment.
Assessment:
Mental Status Examination:
She is a 10-year-old Caucasian female that appears her stated age. She is uncooperative with the examiner, but her parents are present for the evaluation. She is neatly groomed and clean, appropriately dressed. There is no abnormal motor activity noted. Her speech is clear and coherent. It has appropriate tone and volume.
Her thought process is unable to determine due to her unwillingness to discuss the issues that brought her in. There is no evidence of flight of thoughts or looseness of association. She is calm and anxious. Her affect matches her mood or is flat. Denies any hallucinations. Denies suicidal or homicidal ideation. No evidence of delusions. She is alert and oriented x4. Her recent and remote memory is intact. Her concentration is fair and her insight is poor.
Diagnostic Impression:
1. Anorexia nervosa, restricting type (Substance Abuse and Mental Health Services Administration, 2016)
a. Reasons why: intense fear of gaining weight; restriction of intake leading to abnormal weight; lack of recognition of seriousness of bodyweight
2. Major depressive disorder, recurrent ( Bains & Abdijadid, 2022)
a. Reasons why: persistent low mood; decrease in pleasurable activities, lack of energy; appetite changes; sleep disturbances
b. Reasons why not: patient is refusing to eat with the goal of not gaining weight
3. Body dysmorphic disorder with poor insight (Substance Abuse and Mental Health Services Administration, 2016).
a. Reasons why: preoccupation with flaws in physical appearance that are not seen by others; causes social impairment of functioning
b. Reasons why not: does not mention comparing herself to others
Reflections
If I were to see this patient again, I would do everything my preceptor did. With the lack of cooperation from the patient, it was difficult to understand her motivation or goals. I would ask her if she wants to get better or if she thinks that she is doing fine without help. However, she was extremely shy and withdrawn.
I have not been able to do a follow up with this patient yet. If there was progression, then I would discuss
Case Formulation and Treatment Plan:
Discontinue Prozac
Begin Lexapro liquid suspension 5mg/5ml take 5mls for 5 days, then increase 10mls by mouth daily for depression (increases serotonergic affect and decreases dopaminergic effect that will oppose the eating disorder cause) (Strumila et al, 2022).
Prazosin 1mg take 1 tab by mouth daily for night terrors pending blood pressure reading from home
Begin Cyproheptadine 4mg take 1 tab by mouth three times daily for weight gain (Lin et al, 2021)
Follow up in 2 weeks
Continue Cognitive behavioral therapy ( Bains & Abdijadid, 2022)
Educated parents on not forcing intake but monitoring intake. Encourage the use of protein shakes and high calorie meals. Monitor for signs of self-harm or SI. Discussed that parents do not need to see a nutritionist at this time due to lack of patient’s willingness to try foods. Discussed letting the medication take effect and therapy and following up frequently to closely monitor progress or regression.
Risks and benefits of starting medications were discussed. Parents in agreement for treatment. Potential side effects discussed.
Time allowed for questions and answers provided. Provided supportive listening. Patient understood the discussion.
Follow up with PCP for weight check-ins that were previously scheduled and discussed.
Discussed following up sooner if needed for adverse effects or more treatment.
PRECEPTOR VERIFICATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
Bains, N. & Abdijadid, S. (2022, Jun 1).Major Depressive Disorder. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/
Lin, Y., Yen, H., Tsai, F., Chung-Hsing, W., Lung-Chang, C., Chen, A., & Lin, R. (2021, Oct, 19). Effects of cyproheptadine on body weight gain in children with nonorganic failure to thrive in Taiwan: A hospital-based retrospective study. https://doi.org/10.1371/journal.pone.0258731
Strumila, R., Lengventye, A., Olie, E., Quartet, P. & Guillaume, S. (2022, Aug 24). Escitalopram should be investigated in anorexia nervosa: Rationale and review of mechanisms. Journal of Psychopharmacology; 36(9). https://doi.org/10.1177/026988112211183
Substance Abuse and Mental Health Services Administration. (2016, Jun). DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); Table 19, DSM-IV to DSM-5 Anorexia Nervosa Comparison. https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t15/
Substance Abuse and Mental Health Services Administration. (2016, Jun). DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 23, DSM-IV to DSM-5 Body Dysmorphic Disorder Comparison.https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t19/
week seven scot #2
Week 7 : Wk7Assgn2RoseS
Scot Rose
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan I
Subjective: CC (chief complaint):I have been depressed since last Friday with thoughts of suicide
HPI: The patient is a 22-year-old female admitted for suicidal ideation and paranoia.
The patient reports that she has been depressed since last Friday. She states that she unsuccessfully sought help from her family because they were unreceptive and intoxicated. The patient says that she sought help from a friend that was also depressed and planned a double suicide. She has had a long-standing history of suicidal thoughts since the fourth grade. The patient reports feeling empty numbness, diminished interest in activities, worthlessness, decreased energy, and frequent crying. The patient describes that her moods can change within minutes.
She describes negative energy episodes that make her highly irritable and impulsive towards violence. She states that sometimes she thinks about harming her pet dog. The patient reports a history of self-harm by cutting, scratching, and biting herself, especially at work. The patient states that at work, she excessively worries, becomes paranoid, and has GI symptoms. She reports experiencing anticipatory anxiety, agoraphobia, and phobia of the dark.
She states to have intrusive or persistent thoughts that are obsessions that she thinks about for 1 to 2 hours daily but does not want to discuss further. The patient reports having dreams or flashbacks to her traumatic childhood experiences, making her hypervigilant, hyper-aroused, and easy to startle. The patient denies racing thoughts or pressured speech and has not had sleeplessness.
The patient told admitting staff that she sometimes lays in bed and laughs uncontrollably for hours. She reports feelings of being watched and states that she sees a minor black demon that hides in dark areas or shadows. She states to experience derealization weekly for a few minutes at a time but is unbothered by the dissociation.
The patient says that her sleep cycle is variable, with weeks of hypersomnia and episodes of 2 to 3 days where she only gets 2-3 hours of sleep. The patient states that she has had appetite fluctuations and binges and is currently calorie counting to attempt weight loss. She denies seasonality or menstrual mood changes. Over the last two weeks, the patient states that she has been feeling not good, unhappy, angry, bored, tired, scared, worried, and panicked.
Substance Current Use: The patient reports that she occasionally drinks alcohol twice a week, denies drug use, and vapes nicotine.
Social History: The patient states that her parents divorced when she was 2 to 3 years old, and she was raised in Michigan.
She reports that her mother was emotionally abusive, brought strange man home, and neglected her basic needs. The patient states that much of her childhood abuse and neglect occurred while living in Michigan. She moved to Georgia with her mother at eight years old. She says that she moved back to this area at age fifteen to live with her father and grandmother.
The patient states that she felt unable to communicate her needs during her childhood. The patient says she was held back in first grade, caught up by 5th grade, and moved to online school during 10th grade through graduation. The patient currently lives with her father and grandmother. She is single and reports that she had been withholding her sexual identity and recently became lesbian.
She denies any religious affiliation, legal history, or involvement in any social groups. She is not currently employed. Intake staff charted that while the patient was 5 to 8 years old, her mother’s friend had children that would visit, and they experimented sexually with oral, groping, and touching.
Psychiatric History and Medication Trials: The patient reports that her psychiatric history includes complex PTSD, MDD, GAD, social anxiety, mixed obsessive thoughts, and bipolar II disorder. She has been psychiatrically hospitalized between two different facilities, once in 2020 and twice in 2021. She is established with a prescribing provider and therapist.
She reports a good relationship with the therapist and commends her responsiveness. The patient states she had a bad reaction to Prozac, Caplyta- cold, aches and dizziness, and sleep medications – ineffective. The patient states that she feels as though her outpatient medication combination has her about 60% better for the last six months.
Family Psychiatric History: Family psychiatric history includes depression – mother, brother, paternal grandma, and father. Anxiety – mother and brother. Bipolar Disorder – aunt. AODA-paternal grandma, father, mother, paternal great-uncle, maternal uncle. Borderline personality disorder-mother. The patient’s step-great-grandfather completed suicide, and her mother has had suicide attempts.
Medical History: The patient’s medical history includes lower back pain, light/sound sensitivity, eye surgery, elevated cholesterol, liver tear, and dental extractions. The patient reports a concussion in 2021 after intentionally striking her head against a bathroom counter. She denies neurological or seizure disorders.
Current Medications: Current outpatient medications: Vitamin D 5000 units daily, Ativan 0.5 mg daily as needed for anxiety, Wellbutrin XL 300 mg daily, Intuniv 1 mg daily, Vraylar 4.5 mg daily, Trileptal 300 mg twice daily, Imitrex 50 mg as needed.
Allergies: Seasonal allergies and intolerances to proton pump inhibitors – gassy.
Reproductive Hx: The patient denies ever being pregnant.
ROS: All additional systems reviewed were stated unremarkable per the patient.
GENERAL: Reports generalized fatigue
GASTROINTESTINAL: Positive for GI ruflux and bloating
MUSCULOSKELETAL: Positive for lower back discomfort
Objective:
Diagnostic results: CBC, CMP, TSH, UDS, Lipid Panel- All unremarkable. Lithium level ordered for next week to assess level.
Assessment:
Mental Status Examination: The patient is obese and appropriately dressed with blue-dyed hair. She exhibits no tics or tremors. She actively participates during the interview and provides direct eye contact. Her speech is fluent, coherent, and free-flowing. The patient describes her mood as being persistently low and dysthymic. Her affect is congruent with his mood and is of full range. The patient offers thorough answers to the topic of discussion. She endorses visual hallucinations( little black demon) and delusions of being watched.
She reports suicidal thoughts and homicidal or obsessive behaviors. She is alert and oriented to person, place, time, and reason. Memory and concentration are intact per mathematical calculation and recall. The patient displays good insight related to actively seeking mental health management. Her judgment is intact and goal-oriented on maintaining her stabilized behavioral health.
Diagnostic Impression: The patient provided me with a large volume of information to assess her mental health status and from which I prioritized three differential diagnoses. The following diagnoses are triaged according to clinical severity and priority. The first diagnosis I feel is the most relevant for this patient is Bipolar II Disorder-Major Depressive Episode with moderate-severe anxious distress (F31.81).
The second diagnosis I have selected for this patient is Generalized Anxiety Disorder (F41.1). The final diagnosis I have chosen for this patient is Borderline Personality Disorder (F60.3). The patient meets the criteria for bipolar II disorder by meeting the requirements for having a history of hypomanic symptoms and her longstanding depressed mood, diminished activity by staying in bed most days, appetite fluctuations, hypersomnia and insomnia, low energy and poor concentration, and recurrent thoughts of death.
These symptoms affect her ability to work/ socialize and are not attributable to substance use. The diagnosis of Generalized Anxiety Disorder is supported by the patient explaining longstanding anxiety, uncontrollable anticipatory worrying with restlessness, poor concentration, irritability, sleep disturbance, and muscle tension. The patient states that her worrying has made working extremely difficult for her.
The diagnosis of Borderline Personality Disorder could be moved to the primary diagnosis with additional assessments. She meets the following personality traits associated with this diagnosis through her seeking support from multiple peers and family. She appeared to be splitting between her father and grandmother, being supportive and not at all. She stated that she was newly identifying herself sexually and exhibited unnatural hair color, possibly exhibiting identity disturbance. The patient said her moods shift within minutes, and she experiences feelings of chronic emptiness and suicidality. She stated feelings of paranoia and difficulties with irritability.
Reflections: The patient encounter went smoothly, and I collected a significant amount of history during this patient interview. I utilized open questions for most of the discussion and gathered notes as the patient replied. She appeared comfortable with my presence and seemed relaxed throughout the encounter. Additionally, I would like to build my template for performing patient interviews as I find myself jumping around during patient consultations.
Case Formulation and Treatment Plan:
Plan: The patient needs to be provided with a safe and stable environment. The multidisciplinary team will provide the patient with appropriate medication, monitoring, and psychotherapy during hospitalization. Daily assessments will determine the overall efficacy of the current treatment course and the need for treatment modification. The patient agrees to modify her medication therapy by discontinuing Trileptal and weaning off Wellbutrin, as these medications could be ineffective or exacerbate symptoms.
The patient was educated on Lithium and its potential benefits and side effects. She is agreeable to trialing Lithium for her moods. Continue to provide the patient with a safe environment, discontinue Trileptal, cut Wellbutrin XL to 150 mg daily, and start Lithium 450 mg twice daily. On discharge from the facility, recommendation of continuing psychotherapy with an emphasis on DBT. Once the patient agrees that she can be contracted to maintain her safety outside of hospitalization, she may be discharged to self-care.
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References