Week 3: Focused SOAP Note and Patient Case Presentation

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum

September 19, 2021

Introduction

Each mental intervention is based on the evidence gathered during the initial interview

with the patient; each patient's therapy begins with a thorough medical and mental health

evaluation, the incorporation of trust, and a dialogue of past mental health history, substance

misuse history, family mental health history, and so forth. The evaluation of the patient in this

case was documented, and a diagnostic impression was formed based on the information

obtained from the patient during the evaluation. A therapy strategy was devised when the case

was developed. The patient is a 7-year-old Caucasian boy who was scheduled for an initial

screening for a mood disorder after her pediatrician recommended that she consult a psychiatrist.

At this time, the patient is not taking any medications. DDAVP PO was given to the patient, but

it was stopped since it was ineffective.

Patient Initial: R.C Age: 7 Gender: Male

Subjective Data:

CC: "My mother said you will be able to help me with my mood problem"

HPI: R.C a 7-year-old White male who was referred to a psychiatrist for evaluation after several

treatments and efforts by his teacher to help him with his mood. According to patient's

mother during the interview, the mother said that the pediatrician placed patient on DDAVP

which did not help patient. Mother did not list dose of medication or frequency. During the

interview, patient states that he feels worried most time. Patient said " I am worried about

everything". Patient admits to bad dreams and that he dreams a lot that he can't find his brother

and mom. When asked if patient feels lost. Patient responding saying " I worry about my mom

and brother when I am alone". Patient went further to state "People in school don't like me. They

call me smelly and calls me names". Patient said that his mom said his school mates calls him

those names because patient does not take her baths. Patient expressed that he is sad about

it. Patient said sometimes he will have accidents at night. Patient also states that his school

mates his school mates don't know how it feels when your father can't come back home and that

he worried what if his mom does not come home. Patient states that his teacher also picks on him

in class. His teacher was telling him to sit down and focus. Patients admit to harming other by

saying" I have thrown book at Billy". Denies ever causing harm to himself or any intention to

harm himself.

When the mother was interviewed, the mother expressed her concern that patient is

anxious and worry about silly things like his is going to die, that the mom loves his brother more

than she loves him, that the mom won't pick him up in school. Mother expressed that he has a

difficult time going to sleep, learning difficulty, gets in trouble in school, throws things around

the house, wants his light on at night and doors open, has difficult time going to sleep, claims

stomach upset just to be sent home from school, almost daily. He won't eat and has lost some

weight. lost 3 pounds in the last 3 weeks. Mother explained that he wets the bed at night. That

the pediatrician referred them to the Psychiatrist and has prescribed him DDVAP, but the

medication doesn't seem to help. Mother expressed that Rev father was killed in the war but she

thought Rev was too young to know about death, so she didn't tell him his father is late. Mother

feels guilty about not disclosing the death of Rev's father to him and said it was all her fault that

Rev functions this way.

Substance Use History: denies substance use or anyone using substance at home.

Family Psychiatric/Mental/Substance Use History: Patient father had Hypertensin. Patient’s

mother: Anxiety. Brother: Asthma, ADHD and Anxiety. Grandfather: Diabetes and cancer.

Grandmother: Heart disease.

Psychosocial History: Patient lives with mother, little brother and his puppy. Father is deceased.

Both parents are Caucasian. Patient is presently finding difficult to keep friends in school.

Educational Level: Patient is in Middle school. Legal history: No legal history.

Psychiatric History: None

Medical History/Surgical History: Bedwetting

Birth and Developmental history: Vagina birth with no complications. Patient met all

developmental millstones on time.

Current Medications: No current prescribed medication or OTC. Patient was once placed on

DDAVP.

Allergies: NKDA or seasonal allergies

Reproductive Hx: Patient denies sexual history or abuse

APPEARANCE: Dressed appropriately and well groomed

HEENT: No vision problem. Ears normal shape with no discharges. Nose normal shape; no

deviation or drainage. No sore throat or swelling around the neck.

CV: no cardiovascular abnormality

PULMO: Lungs sounds clear and no adventitious lung sounds

ABDOMEN: All bowel sounds on all four quadrant

GENITOURINARY: No disorder or problem with this system

EXTREM: All extremities is moveable; some tremors noted in upper extremities

NEURO: alert and oriented to person, place, time, and situation but very unrest

SKIN: Skin intact and appropriate; no rash or lesion noted

Physical exam:

Vital Signs: none at this time

Weight: 51Ibs

Height: 4 ft

Diagnostic results:

PHQ 9: Scored 13

GAD 7: scored 10

Objective:

Diagnostic results: no diagnostic test ordered or required at this time

Assessment:

Mental Status Examination

Patient appeared stated age, no apparent distress on arrival and during the session. Patient and

baby appears well nourished, well groomed. Well dressed and clean. Patient was cooperative, not

fidgeting, makes good eye contact and able to sit still. Patient appears to be anxious and worried

Affect was full range, somewhat constricted and often sad. Able to stay still. No abnormal

movement noted. Gait steady and posture upright. Patient was coherent but not very logical due

to worry. No acute psychosis or mood symptoms. No delusions or paranoid

behavior noted. Patient has some intrusive thoughts. Patient’s speech was normal rate, rhythm

volume and clear. Patient does not feel like she will get better. She had a good judgment and

recognized what she needs to be done to care for her baby. Patient was attentive to the provider

and attentive to the baby’s needs while she learn. Alert and oriented times 4. Memory both long

and short term was intact. Patient denies suicide ideation. Patient admits having intrusive

thoughts of hurting baby but patient finds this thoughts upsetting and denies intent. Patient states

she removes herself in situation that can cause harm to baby.

Differential Diagnoses

Adjustment Disorder: "Adjustment disorder is a maladaptive response to recognized

psychosocial stressors or life changes that is characterized by obsession with the stressor and

failure to adapt." Within three months of the initiation of a specific stressor, disorder is defined

as the appearance of emotional or behavioral symptoms in reaction to the stressor. Adjustment

can result from expected or unexpected events, and it can lead to disorder, causing an individual

to feel confused, worried, anxious and disoriented (disoriented), preventing him from going

about his normal routine. Separation, dissolution of marriage, the termination of a long-term

relationship unexpected death of a loved one, the loss of a career, being cheated on by a partner

or spouse, being the victim of a sexual assault are all examples of stressful events that can result

to adjustment disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

(DSM-5) must be completed within three months after the commencement of the stressor or

stressors. In addition, one or both of the following conditions must be fulfilled: Clinically

significant distress is defined as distress that is out of proportion to the predicted stressor

reactions and symptoms. They cause a lot of pain and make it difficult to function (American

Psychiatric Association, 2013).

Generalized Anxiety Disorder: Excessive anxiety and worry regarding a number of events or

activities, happening more days than not for at least 6 months (such as work or school

performance). GAD (generalized anxiety disorder) is a mental health issue that affects both

children and adolescents. A youngster with GAD experiences a lot of worry and terror for no

apparent reason. Worry may be excessive in comparison to the situation. Physical appearance,

prior habits, social acceptance, family difficulties, failing to fulfill parents' expectations, personal

abilities, and academic success are all common concerns for children and teens with GAD.

Generalized Anxiety Disorder is a natural stress response that, in certain cases, can be beneficial.

It can alert us to potential risks and help us plan and pay attention. Excessive dread or anxiety

characterizes anxiety disorders, as opposed to normal feelings of apprehension or anxiety.

Anxiety disorders are the most prevalent mental illnesses, affecting almost one-third of all adults

at some point in their lives. Diagnostic Criteria for Generalized Anxiety Disorder (GAD) in the

DSM-5: Excessive anxiety and worry (apprehensive expectancy) about a number of events or

activities, occurring more days than not for at least 6 months (such as work or school

performance), the individual has difficulty controlling his or her anxiety, and three (or more) of

the following six symptoms are linked to anxiety and worry: Being easily fatigued, having

difficulty concentrating, or having your mind go blank are all indicators of restlessness or

agitation. Irritability manifests itself in the form of irritability, muscle tension, and sleep

difficulties (American Psychiatric Association, 2013).

Dysthymic Disorder: Depressed mood for most of the day, for more days than not, as indicated

by subjective account or observation by others, for at least 2 years. Presence while depressed of

two or more of the following: Poor appetite or overeating, insomnia or hypersomnia, low energy

or fatigue, low self-esteem, poor concentration or difficulty making decision, feelings of

hopelessness. The disturbance is not caused by a substance's direct physiological effects (e.g., a

drug of abuse or a medicine) or a general medical condition. Clinically substantial distress or

impairment in crucial areas of functioning are caused by the symptoms. Although dysthymia was

once thought to be less severe than major depression, its implications are now widely

acknowledged to be serious, including significant functional impairment, increased morbidity

from physical disease, and an increased risk of suicide.

To determine a diagnosis of Dysthymic Disorder, the DSM-5 provides the following criteria.

During the 2 years period, the person must have five or more symptoms, with at least one of

them being either (1) sad mood or (2) lack of interest or pleasure. Changes in energy level,

depressed mood most of the day, nearly every day, decrease or increase in appetite nearly every

day, poor self-esteem, anxiety, isolation, appetite change, forgetfulness, not completing assigned

chores at work or school, guilt, and loss of energy are all listed in the DSM-5 (American

Psychiatric Association, 2013).

Reflection

Every mental intervention is determined by the information collected during the initial

conversation with the client; every client's therapy starts with a comprehensive medical and

behavioral health examination, the creation of trust, and a discussion of previous mental health

history, substance abuse history, family mental health history, and so on. Individuals with whom

they had connections that comprised effective communication, cultural awareness, and the

absence of compulsion were considered as trustworthy (Sadock et al., 2014). One thing I might

have done differently as a PMHNP is to meet the patient first, establish a therapeutic

relationship, ask the young patient about his relationship with his parents, and then ask questions

unrelated to the scheduled visit, which would help to create a welcoming atmosphere. Ask open-

ended inquiries on the patient's personality, ailment, or personality without appearing to have a

bias. Inquire about the patient's sexual orientation and preferred method of communication.

Cultural competency includes elements such as trust, respect for diversity, respect for religion,

equity, fairness, and social justice, which must all be considered during any interview or

encounter between a healthcare practitioner and a patient (Sadock et al., 2014). When I interview

a patient about their mental illness symptoms, I look at how they look, speak, and act to

determine if there are any clues that could explain their symptoms.

Case Formulation and Treatment Plan

The patient will begin individual supportive therapy then advance to family and peer

group supportive therapy depending on level of improvement. The patient’s mother will receive

an educational pamphlet, as well as assignments and a follow-up consultation, on themes that

will aid in the healing and coping process.

Patient will be started on fluoxetine (Prozac). An initial dose of 10 mg/day then increased

to 20 mg/day after 1 week. Education and side effects of medication was provided for mother

and son.

Bedwetting can be avoided by limiting how much a child drinks in the evening, avoiding

caffeinated meals and beverages, and promoting regular toilet usage throughout the day. Mother

was told to wake the patient up at night to urinate and to make sure the patient's clothing were

changed before going to school in the morning. Personal hygiene assistance should be provided

to the patient.

In case of emergency, the provider provided patient with helpful phone numbers: 911 for

emergencies and the Client's Crisis Line. Reports from doctors and therapists were evaluated for

mutual and collaborative understanding and for continuity of care.

Patient’s mother was educated and was advised to call their primary care physician or go

to the nearest emergency department if they had any questions or concerns about the

development of any undesirable or unexpected outcome or side effects.

Every 30 days, patient must return to psych tele-appointments for continuity of care and

for provider to monitor progress and outcome of treatment but patient will return a week after

starting Prozac for adjustment of dosing and to monitor improvement.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders, fifth edition DSM-5 American Psychiatric Association, 2013.

Bachem, R., & Casey, P. (2018). Adjustment disorder: A diagnosis whose time has come.

Journal of Affective Disorders, 227, 243-253. https://doi.org/10.1016/j.jad.2017.10.034

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry:

Behavioral sciences/clinical psychiatry (11 th ed.). Philadelphia, PA: Wolters Kluwer.

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A.

(Eds.).

(2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley

Blackwell.

Walden University. (2021). Case study: Dev Cordoba. Walden University

Blackboard.

https://class.waldenu.edu