NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

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Subjective:

CC (chief complaint): patient presents to the facility complaining that the drugs she has been prescribed make her feel squashed.

HPI: P. P. is 26years old female who presents to the facility for mental health evaluation. The patient has suffered mental health since teenage. She has been prescribed several medications which she states to stop taking at some point.

Substance Current Use: the patient smokes a pack of cigar daily. No other substance used by patient.

Medical History: patient has been hospitalized about four times. She has not had any surgeries or blood transfusion in the past. Patient states to have been diagnosed with depression, anxiety and even bipolar disorder. The patient is being treated for hypothyroidism as well.

· Current Medications: patient is currently not taking psychotropic medications. She has stopped taking the previously prescribed drug whose name she doesn’t know.

· Allergies: patient has no known allergies.

· Reproductive Hx: patient has a boyfriend, but has also sexual partners. She says that it makes her feel good having multiple sexual partners. Patient is not sure of the last menstrual date, but she states that she is not pregnant. She is taking oral contraceptive as well.

ROS:

· GENERAL: patient looks healthy. he does not report fatigue or weakness.

· HEENT: head: head is normocephalic, eyes: no blurred vision discharge, or pain. ears: no ringing in the ears, discharge or pain. hearing ability has not diminished. nose: no runny nose or postnasal drainage. throat: no sore throat, no pain or difficulty with swallowing.

· SKIN: no bruising, rashes or tumors

· CARDIOVASCULAR: no palpitations, chest pain or edema reported

· RESPIRATORY: she denies breathlessness, coughing and wheezing.

· GASTROINTESTINAL: patient states that his stomach muscles become tight and feels nauseated.

· GENITOURINARY: no urgency or frequency of urination

· NEUROLOGICAL: she denies seizures, headaches, blackout spells, and numbness

· MUSCULOSKELETAL: she denies stiffness of the joints, pain, tenderness or inflammation

· HEMATOLOGIC: she denies abnormal bleeding or anemia.

· LYMPHATICS: lymph nodes normal size, not enlarged or painful.

· ENDOCRINOLOGIC: no night sweats or increases thirst

Objective:

Diagnostic results: none

Assessment:

Mental Status Examination:

She a 26-year old female whose stated age seems to correspond with her ages. She is oriented to time, place and person. She is very cooperative and answers questions appropriately. She is clean, and her hair is well combed although her dressing is somehow rough. The patient is hyperactive, playing around with her fingers and laughing more frequently. Her voice is normal, with normal tone and clear. Her thought process is logical and relevant to the setting. She states to have had auditory hallucinations some time ago, and there is evidence of delusional thinking, since the patient claims of some periods when she is creative and others that she is not. Additionally, the patient has had suicidal ideations but no thoughts of harming anyone. Her memory is intact and has good concentration power.

Diagnostic Impression:

Differential diagnosis:

· Schizophrenia: It is a severe psychiatric disorder which makes victims to have abnormal interpretation of reality. It may manifest through hallucinations, delusions and illogical thinking (WHO, 2019). This is not considered to be the primary diagnosis since the patient is oriented and in contact with reality. Additionally, the patient does not have hallucination apart from a single episode she had after a drug overdose.

· Major depressive disorder: major depressive disorder is another possible diagnosis which is characterized by a depressed mood and changes in appetite and alteration of sleeping patterns. However, it is not accompanied by manic episodes as seen in this patient.

· Hypothyroidism: since the patient suffers from hypothyroidism, it is possible that the episodes of depressed mood are due to hypothyroidism (Roybal, 2007). It is not considered as primary diagnosis due to the specific manifestations like increased sensitivity to cold which is absent in this patient. Hypothyroidism is not associated with alterations in sleeping patterns and appetite as ween in this patient.

My primary diagnosis for this patient is bipolar disorder. Bipolar disorder can cause patients to have extreme mood swings from a feeling of high to low mood (Hirschfeld, 2014). The patient states that she has once been taken down by the cops to the hospital for dancing out in a night gown. Additionally, the patient. Additionally, bipolar disorder is characterized by patient exhibiting an excessive desire for sex as seen in this patient.

Reflections:

From this case, I can say that the examiner is quite comprehensive in gathering patient history. He has made sure to question every aspect of the patient to ensure that the patient provides as much information as possible. As for me, I would not do much different assessment of the patient from the examiner. The patient states to have stopped her current psychotropic medication due to the squash feeling, and hopes to be prescribed a better drug that could keep her high and motivated. Additionally, the patient stated clearly that he cannot quit smoking, which would present a barrier during health promotion in the patient. Advising the client to also limit the number of sexual partners to one could helpful to prevent Sexually Transmitted Diseases and unwanted pregnancies which would increase her depression.

Case Formulation and Treatment Plan:

The risk of combining prescription medication with other unprescribed medications was discussed. she was advised to abstain, or maintain one sexual partner. Patient was educated on impacts of psychoactive drug to mental health, sleeping patterns as well as physical health.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist): the patient was referred to a psychiatrist for further evaluation and treatment.

Client was encouraged to continue with case management and/or therapy services.

Client has emergency numbers: Emergency Services 911. Client instructed to go to nearest ER or call 911 if they developed

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion.

Patient was given enough time to ask questions, while substantial answers were provided. She seemed to comprehend the assessment and teaching.

Return to clinic: she was advised to return for follow up after four weeks.

References

Hirschfeld, R. M. (2014). Differential diagnosis of bipolar disorder and major depressive disorder. Journal of affective disorders, 169, S12-S16.

Roybal, B. (2007, February 1). Hypothyroidism and depression. WebMD. https://www.webmd.com/women/guide/hypothyroidism-and-depression

WHO. (2019, October 4). Schizophrenia. WHO | World Health Organization. https://www.who.int/news-room/fact-sheets/detail/schizophrenia

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