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

Week 9: Grand Rounds Discussion: Complex Case Study Presentation
Tammy Ross

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Dr. Connole-Pond

07/25/22

The comprehensive focused evaluation can be used to guide the provider to establishing a treatment plan that will address the chief complaint. The purpose of this assignment is to present an adolescent client from the practicum environment, which can incorporate engaging elements of Blooms Taxonomy to enhance learning while addressing the client’s needs. Mentioned by Zaidi et al. (2018) Bloom’s Taxonomy has six domains which include knowledge, comprehension, application, analysis, synthesis, and evaluation. As each domain can be assist with critically thinking and clinical reasoning.

Objective Questions Using Bloom’s Taxonomy elements

How would you use the process of application to produce an engaging therapeutic family session which is held via zoom for the client and parent based on the information presented in the case study?

How would you assure comprehension has occurred of the client and parent’s understanding the diagnosis of Bipolar II Disorder and medication that has been prescribed?

In an analysis of this case study what information about the biological parents could have help to understand the client’s current mental status?

Subjective:

CC: “I have been having mood swings that aren’t getting better and my mother is concern.”

HPI: A.J. identities as a single African American female17 years old. Has been referred from her primary care provider for a comprehensive focused evaluation. Client’s mother reports her daughter has been having mood swings for the duration of 2 weeks. In which the mother reports symptoms range from periods of being depressed, crying, lack of motivation, to periods of extreme happiness, laughing at inappropriate situations, and promiscuity. The frequency of the symptoms are ongoing and vary in presentation thought the day. The severity of the symptoms has caused her mother to take her car away from A.J for a month, as A.J. admitted to meeting up with male teenagers for sexual activity when her mood has been elated. The client reports sleeping for 10 hours when she is feeling down and still doesn’t feel rested, and other times she is up for 2-3 days with just a few hours of sleep. Client reports that when she has diminished sleep task such as cleaning her room, bathing the dog and other chores around the home are completed sooner. Client denies suicidal and homicidal ideations when asked. Client reports no auditory or visual hallucinations when asked.

Past Psychiatric History: None

Caregiver: Adoptive mother

Hospitalizations: None

Medication trials: None

Psychotherapy or previous psychiatric diagnosis: None

Substance Current Use: Denies use of illicit drugs, nicotine, vaping, alcohol, or consuming caffeinated drinks.

Family Psychiatric/Substance Use History: Client was given up for adoption at birth and little is known about her biological parents.

Psychosocial History: A.J., was born in Miami, Florida. She was adopted a few weeks after birth due to the biological parents not having the means to raise a child. She has been raised by a single parent in which she resides in Washington D.C. She has no siblings. Her religion is Baptist. Plans to attend college in the fall for computer engineering. Favorite subjects are history, math, and science. Hobbies are basketball will be attending college on a full basketball scholarship in the fall. Reports that she eats from all the food groups, no changes in appetite. Has no legal issues pending past or present. Supported by her mother that has worked as a real estate agent for the last 20 years. Has a best friend that she has known for 8 years Samantha who is also a basketball player, which they go on social outings together such as movies, lunch, and shopping. She reports no childhood trauma. Has no concerns within the home, reports living in a safe loving environment.

Medical History:

· Current Medications: IUD implant had for 14 months that contains etonogestrel for birth control

· Allergies: NKDA

· Immunizations: Are current

Reproductive Hx: menstrual cycles light, regular and non-painful, LMP period was two days ago. sexually active, heterosexual, reports no std’s/sti’s and uses condoms for protection to reduce risk of pregnancy.

ROS:

GENERAL: + for fatigue, no weight loss, no fever, mood swings

· HEENT: Head: reports no H/A or head trauma. Eyes: no issues reported. Ears. No issues no pain. Nose: No issues with drainage. Mouth: No problems with teeth or chewing food/Throat no problems swallowing.

· SKIN: Client reports no lesions or wounds

· CARDIOVASCULAR: Denies having chest pain or discomfort

· RESPIRATORY: Reports no shortness of breath

· GASTROINTESTINAL: Last BM 7/23/22 per client no constipation.

· GENITOURINARY: Reports no urine odor, and its “clear light yellow.”

· NEUROLOGICAL: No reports of falling or seizures

· MUSCULOSKELETAL: Reports no limitations with range of motion.

· HEMATOLOGIC: No transfusions

· LYMPHATICS: No reports of lymph node swelling

· ENDOCRINOLOGIC: Has no reports of hot or cold intolerance

Objective:

Physical Examination:

Vital Signs: B/P 102/66, HR 68, T. 98.0, R16, HT 6’6’ft. Wt 170lbs, BMI 20

General: A&0X3, dressed appropriately for the season, euphoric, speech rapid at times, athletic build

HEENT: Normocephalic, no lesions present. Eyes: Sclera white bilateral without drainage, PERRLA, EOMI. Ears: No drainage hearing intact bilateral, tympanic membrane appears light gray in color. Nose: No drainage, no polyps. Teeth. Intact. Throat: No JVD. Thyroid: No masses and non-palpable.

Complete physical examination is not applicable to this setting and is completed by primary care provider.

Diagnostic results:

Urine Toxicology Screen: Mentioned by Moeller et al. (2017) the use of urine toxicology screen can assist to identify substance abuse. Results were negative today.

Electrocardiogram (EKG): According to Broszko and Stanciu (2017) EKG should be obtained before placing any patient on psychotropic medications due to the risk for QT prolongation. This supports the reason for obtaining an EKG prior to initiation of psychotropic medication, and at intervals or when there is medication change. Results normal sinus rhythm today.

Patient Health Questionniare-9 (PHQ-9): Was obtain as there was mentioned of depression within the HPI. Mentioned by Costantini et al. (2020) the use of PHQ-9 assists in screening for depressive characteristics. The client’s score was a 5 which indicates mild depressive symptoms, obtained today. This information will help to develop the treatment plan.

Laboratory: CMP, TSH, CBC with differential, Kidney Function Test, A1C, Lipid Panel, Liver Function Test, and STI panel. Mentioned by Nederlof (2018) laboratory results can assist in identifying underlying medical conditions and the effects of medication on the human body. Results are in normal limits for this individual 7/20/22.

Assessment:

Mental Status Examination: A.J. is a 17-year-old African American female that appears her stated age. She has been cooperative with this provider during this encounter. She presents well groomed, dressed appropriately for the season. Has a euphoric presentation and smiling at times when there is mentioned of her promiscuity. Yet the client will have mood swings in which depressive symptoms are noted and she can become tearful as she was at various periods with this provider encounter. She is positive for fatigue as she reports being up for the last two days with little sleep. In which at other times hypersomnia occurs in which she sleeps for 10 hours. Speech rapid at times. Alert and Orient x 3. Logic reasoning and judgement are poor as this has been exhibited by engaging in risk sexual behavior. Mood is depressed as the Personal Health Questionnaire-9 score was a 5 which supports mild depressive symptoms. Concentration is poor as during this interview questions have been repeated several times, as she is unfocused. No presents of involuntary movements or tics.

Differential Diagnosis:

Bipolar II Disorder: According to Nicholson (2022) for the DSM-5 criteria there would need to be a period of elevated mood or irritability for at least 4 consecutive days, and alternations from hypomania to depressive state. Which the client has been in a euphoric mood currently. Her mother has observed the client’s mood swings from depression in which there is noted hypersomnia, to periods were there is sleep disturbances in which little or no sleep is required, and she is up for 2-3 days. During this encounter with the client there was poor concentration, crying at times and rapid speech notice which are part of the Bipolar II Disorder symptomology. Mentioned by Nicholson there is an intensity in seeking pleasure. The client has been engaging in risky sexual activity with random teenage males that she doesn’t really know. Currently Bipolar II Disorder is the selected differential diagnosis currently.

Attention Deficit Hyperactivity Disorder (ADHD): Noted by Drechsler et al. (2020) in alignment with the DSM-5 there needs to be at least two symptoms of ADHD by age 12, and for individuals 17 and older 5 symptoms. As for this client she has in attentiveness as there is poor concentration, and impulsive behavior as she doesn’t think about the risk from her actions related to promiscuity. According to Drechsler the symptoms need to occur in at least 2 different settings.The client doesn’t meet the criteria as she doesn’t have five symptoms and there is no indication of at least two setting in which symptomology has occur. Therefore, this differential diagnosis wasn’t selected.

Major Depressive Disorder: Mentioned by Bains et al. (2020) for DSM-5 criteria there needs to be a depressive state for two weeks which is continual. The client hasn’t been in a depressive state for two weeks. She doesn’t meet the guidelines for this differential diagnosis, so it wasn’t selected.

Diagnostic Impression: The client is accurate with information of her status. She can make her needs known. The information has been gathered from the client,her mother, lab results, and assessment tools to assist in developing a different diagnosis of Bipolar II Disorder. As her mood fluctuates from euphoric to depressive. In which the symptoms have been occurring for two weeks. In which client has been reported being in an elated mood, then times when there is low energy and tearfulness. There has also been promiscuity as she seeks pleasure when her mood is euphoric. The differential diagnosis of ADHD and Major Depressive Disorder were both ruled out as she didn’t meet the DSM-5 criteria for either of those diagnosis. She has been raised by single parent that adopted her when she was an infant. She doesn’t know her biological parents. The client was respectful of her adoptive mother during this encounter, in which she calls her “mom.” She has a positive support system which includes her mom, best friend, and church which she attends. Client has acknowledged a need for help. As there are safety concerns due to the activity in which she is engaging in. To improve client’s current mental status and reduce negative outcomes; psychotherapy and medication management appears beneficial options for the client.

Reflections, Legal and Ethical Considerations, and Health Promotion:

This assignment was complex as in working with an adolescent and parent to develop a treatment plan that would be supported by both. In reflecting upon the assignment, I’m in agreement with my preceptor’s assessment and diagnostic findings of the information presented in clinic. I have learned that adolescent’s clinical presentations can vary from that of an adult. In hindsight I would have ask the client how she felt when she found out she was adopted, as there could have been a trauma or additional stressors, which could have supported a different diagnosis. Legal and ethical consideration as a provider I must maintain transparency within the treatment plan and discuss the risk and benefits of the recommendations within it, in a manner that can be understood by the client and parent. Health promotion took place in the form of education on sleep hygiene, balanced diet, and exercise to support medication management and wellbeing.

Case Formulation and Treatment Plan:

The client and parent have been informed of the risk and benefits of the use of psychotherapy and psychotropic medication. Both the client and parent agree with current treatment plan and consent has been obtained from parent. A safety plan has also been established. Client and parent have been made aware of the clinic hours and have been advised to go to nearest emergency room after hours if there are safety concerns or medication reaction. They have been made aware of the need for bloodwork at intervals to support medication management and treatment modalities Next appointment in office August 1st at 4pm for reassessment. Client is to attend individual CBT once a week to improve coping skills and to deter negative behaviors starting August 8th at 4pm via zoom. Family therapy sessions are to occur once a month starting August 19th 6pm via zoom.

Treatment Plan

1. Aripiprazole 2mg daily for two days then discontinue

2. Aripiprazole 5mg daily for two days then discontinue

3. Then start Aripiprazole 10mg daily to continue daily for Bipolar II Disorder

4. Fluoxetine 10mg each evening for depressive symptoms

5. Follow up call to patient by day two too check in on medication management

6. Client to return to clinic in one week for reassessment including PHQ-9

7. Individual CBT once a week via zoom

8. Family Therapy once a month via zoom

9. Education on diet, exercise, and sleep hygiene to support medication management occurred today

10. Labs to be repeated in 3 weeks Laboratory: CMP, TSH, CBC with Differential, Kidney Function Test, Lipid Panel, Liver Function Test Then at 3 months

11. Labs to be repeated in 4 months are EKG and A1c

12. Vital Signs including weight, BMI, and PHQ-9 to occur with each encounter

Conclusion

The use of the comprehensive assessment helped in creating a treatment plan for the client. In which the client’s mother also supported. The treatment plan which includes medications and therapy are to help with addressing the chief complaint. As a provider it will be important to continue to utilize assessment tools and client’s clinical presentation to support treatment modalities.

References

Bains, N., Abdijadid, S., & Miller, J. L. (2022). Major Depressive Disorder (Nursing). In

StatPearls [Internet]. StatPearls Publishing.

Broszko, M., & Stanciu, C. N. (2017). Survey of EKG monitoring practices: a necessity or

prolonged nuisance? American Journal of Psychiatry Residents’ Journal.

Costantini, L., Pasquarella, C., Odone, A., Colucci, M. E., Costanza, A., Serafini, G., …

& Amerio, A. (2021). Screening for depression in primary care with Patient Health

Questionnaire-9 (PHQ-9): A systematic review. Journal of affective disorders, 279, 473-483.

Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD:

Current concepts and treatments in children and adolescents. Neuropediatrics, 51(05), 315-335.

Moeller, K. E., Kissack, J. C., Atayee, R. S., & Lee, K. C. (2017). Clinical interpretation of

urine drug tests: what clinicians need to know about urine drug screens. In Mayo Clinic Proceedings (Vol. 92, No. 5, pp. 774-796). Elsevier.

Nederlof, M. (2018). Monitoring patients using psychotropic drugs.

Nicholson, S. D. (2022). Diagnostic status of bipolar II disorder. Progress in Neurology and

Psychiatry, 26(2), 20-23.

Zaidi, N. L. B., Grob, K. L., Monrad, S. M., Kurtz, J. B., Tai, A., Ahmed, A. Z., … &

Santen, S. A. (2018). Pushing critical thinking skills with multiple-choice questions: does Bloom’s taxonomy work? Academic Medicine, 93(6), 856-859.

© 2021 Walden University Page 1 of 3