NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template Respond to WAN Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their Discussion presentations

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

Respond to WAN

Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their Discussion presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

2 citations and two references.

Week 7:

Sudent name : Wan

College of Nursing-PMHNP

PRAC 6675: PMHNP Care Across the Lifespan II

July 14, 2021

Objectives:

1. Identify the criteria for diagnosing a patient with Bipolar Disorder, current episode mixed, unspecified during the mental health assessment

2. Describe the reasons for my differential diagnosis?

3. Develop the best treatment plan that will benefit this particular patient

Subject

CC: Patient states, “I am here because I want to kill my family because they don’t include me in

anything”.

HPI: AM is a 15-year-old Caucasian female referred to the Bradley Center involuntary by

Rivertown psychiatry for homicidal thoughts, intent to kill her family, and auditory

hallucinations. The patient states that she went into her sister's room while the sister was sleeping

and tried to cut a vein in her legs. The patient says, "that the voices told me to cut her and to take

my entire family out." The patient states that after she killed her sister, her brother would be

next. The patient says that the knife did touch her sister's leg before she awakens, making

superficial cuts. The patient states that if I kill them, my life would be better off. The patient says

that she has been hearing voices telling her to kill her family for about one month. The patient

has a history of major depressive disorder and psychosis.  

 Substance Current Use: No substance use

 Medical History: No medical history

 Past Psychiatric History-Greenleaf psychiatric facility November 2020 for suicidal thoughts.

 

 Current Medications: Latuda 20mg daily for depression associated with bipolar disorder,

Lamictal 25mg daily

 

Allergies: NKDA

 Reproductive Hx: None

 ROS: 

·    GENERAL: No weight loss, fever, chills, weakness or fatigue

 

·    HEENT: No visual loss, blurred vision, no hearing loss, congestion or runny nose

 

·    SKIN: No rash or itching

 

·    CARDIOVASCULAR: No chest pain, chest discomfort, chest pressure or edema

 

·    RESPIRATORY: No shortness of breath or cough

 

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

 

·    GENITOURINARY: No burning, urgency, hesitancy, or odor

 

·    NEUROLOGICAL: No headaches, dizziness or syncope

 

·    MUSCULOSKELETAL: No back pain, joint pain or stiffness

 

·    HEMATOLOGIC: No anemia, bleeding, or bruising

 

·    LYMPHATICS: No history of splenectomy, no large nodes noted

 

·    ENDOCRINOLOGIC: No sweating, cold or heat intolerance

 

Objective:  

 

Vital Signs: B/P-98/58, HR-67, RR-20, T-36.9, O2 Sat-100%, HT-163.8cm, WT-65.4 kg

 

Diagnostic results: None

 

Assessment:

 

Mental Status Examination: 

AM is a 15-year-old Caucasian female who looks her stated age. She is making good eye contact

and cooperative. She is dressed and groomed appropriately. There is evidence of psychomotor

retardation. Her thought process is goal-oriented and illogical. Her mood is depressed, and her

affect constricted and flat. At the time of the assessment, the patient reported having auditory,

command, and visual hallucinations of her family dead. There are homicidal thoughts present,

plan, and intent. The patient denies suicidal ideations. She is alert and oriented x 4.  Her recent

and remote memory is intact. Her concentration is good. Her insight is impaired, and her

judgment is flawed.

 

Diagnostic Impression: 

 

F31.60-Bipolar disorder, current episode mixed, unspecified- The criteria to be diagnosed

with bipolar disorder is there is a distinct period of abnormally and persistently elevated,

expansive, or irritable mood and abnormally persistently increased activity or energy, lasting at

least four consecutive days and present most of the day, nearly every day. The patient stated that

she had been hearing voices for the past 30 days and had thoughts of hurting her family. Mixed

features refer to the presence of high and low symptoms co-occurring, or as part of a single

episode, in people experiencing an episode of mania or depression. In most forms of Bipolar

Disorder, moods alternate between elevated and depressed over time (Hu, Mansur & McIntyre,

2014).

Differential Diagnosis:

 

F33.1 Major Depression Disorder-The criteria to be diagnosed with MDD, mood most of the

day, nearly every day. Diminished interest or pleasure in all, or almost all, activities most of the

day. Nearly every day (Mullen, 2018). The patient states that she wanted to kill her family

members due to the voices and never include her in activities. The patient has a history of MDD.

 

F41.1 Generalized Anxiety Disorder-The criteria for this diagnosis is excessive and

uncontrollable and irrational worry, that is, apprehensive expectation about events and activities.

This patient has been having irrational worrying when the family does not include her in the

Circumstances (Gale & Millichamp,2016). She probably doesn't feel loved by her family. The

patient states that she does not have any friends or needs any friends.

 

Reflections: I agree with my preceptor's assessment and diagnostic impression of Bipolar

Disorder, current episode mixed, unspecified. The patient came to the Bradley center with

command auditory and visual hallucinations and homicidal ideations with plan and intent. The

patient should be admitted as an inpatient to get stabilized on medication. The multidisciplinary

team needs to determine what has happened on the last inpatient admission. The team needs to

find out what has worked in the past to help this patient. This is a very delicate situation that

could affect the child and family for life. I would see if the patient has been in compliance with

the medications and educated the child and family on the importance of medication management.

If she is not taking the drug, I would see why. The patient could be having side effects of the

medication or if the medication needs to be adjusted or changed. Some health promotions are to

have patient engagement within their communities, school, organizations, peer groups, and

churches which are constructive. The community engagement would be constructive since the

adolescent states she doesn't have any friends have any pleasure in doing anything. This will give

the teenagers opportunities to feel wanted and appreciated. Some ethical and legal situations are

that the child should be treated with respect and support at all times. Everyone must work

together to ensure that the child feels she belongs and is loved. While the child is in school, the

teacher must be vigilant about what is happening in the classroom. The teacher should engage

the adolescent with other adolescents by having group projects where communication is crucial.

The teacher should build rapport with the adolescent to ensure that it can be identified and

reported if the adolescent has issues such as abuse. The provider must understand the family's

social and economic status due to the ability to afford the prescribed medication.

Case Formulation/Treatment Plan

The patient will be restarted on her Lamictal and Latuda. The patient will be started on Lamictal

25mg daily to stabilize her mood. Education will be provided to the child in the family that

Lamictal can cause drowsiness when first started. Some side effects of Lamictal are nausea,

insomnia, running nose, headache, diarrhea, abnormal dreams, dizziness, and tiredness. The

family should be educated on if the symptoms persist notify the provider (Carandang et al.,

2007). Latuda helps the child think more clearly, feel less nervous, and take part in everyday

life. It can also help with a decrease in hallucinations. Educate the patient and parents on the

importance of if the child is taking birth control pills; the medication could cause the drugs to be

less effective (Goldmen et al., 2017). The next plan is to see if the patient's symptoms persist if

the child can live with another family member, so the child could be placed with someone shet

trusts and not be placed in another facility, such as residential. The child will need intensive

family therapy with wrap-around services through New Horizons to have a therapist come out to

the home until she becomes stable.