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

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

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

Week 7 Grand Rounds Discussion: Complex Case Study Presentation

Student name: KA

College of Nursing-PMHNP

PRAC 6675: PMHNP Care Across the Lifespan II Practicum


Assignment Due Date :7/14/2021

Objectives for the Presentation

After this presentation:

· Objective 1

The audience will be able to list the diagnostic criteria of Bipolar I as per the DSM 5 definition.

· Objective 2

The audience will be able to list one FDA approved pharmacological treatment modality for the management of bipolar disorders.

Objective 3

The audience will be able to list one evidence -based psychotherapeutic treatment for the management of bipolar disorder.



(Chief complaint): ”I don’t know what’s going on with me. I hope you can help me feel better with my mood swings”.


CK is a 25-year-old African American female. She reports that she had a severe manic episode 1 month ago and was hospitalized at a local hospital. After this episode, she reports she was very depressed for a week. She has 2 small children and she said she called CPS and said she was overwhelmed and afraid she could not handle her kids anymore. She gave the kids to her aunt. The patient said her anxiety is 2/10 at this time and her depression is a 7/10. She was started on Lexapro 20 mg PO daily a month ago. she is also prescribed Vraylar 4.5 mg cap daily. She reports feeling better and denies mania currently. she denies SI/HI/AVH. she said she has good family support system. She is also willing to start therapy next week. The patient reported that she was diagnosed with depression, and bipolar disorder in the past.

Past Psychiatric History

The client has a history of bipolar disorder and Major Depressive Disorder(MDD). The patient recalls that when she was 15 and in high school, she had a period of time where she went as many as 5 days with very little to no sleep. She said during that time, she was very hyper and had racing thoughts and felt very irritable and “wired” with a lot more energy than usual. She said her mother recalled her changing boyfriends and having sexual indiscretions. She reports that her mother got worried and took her to the ER. She said she was started on medications but not she did not continue taking the medications and does not remember what the names of the medications. She denies Suicide Ideation, homicide ideation at present. The client shared those 2 or 3 times a year she has episodes where her mood is very depressed most of the days and she has feeling of interested in anything. She even reports during those times, she barely can sleep and lacks energy to do anything and stays in bed all day. She also reported during these depressive periods, she feels worthless and have difficulty concentrating during that same time.

Current Medications: The patient reports that she was started on Lexapro 20 mg PO daily a month ago. she is also prescribed Vraylar 4.5 mg cap daily. She reports these two medications seem to help her.

Psychotherapy: The patient has never tried psychotherapy. Swartz & Frank (2001)noted that although pharmacotherapy is the mainstay of treatment for bipolar disorder, medication offers only partial relief for patients. Treatment with pharmacologic interventions alone is associated with disappointingly low rates of remission, high rates of recurrence, residual symptoms, and psychosocial impairment. Bipolar-specific therapy is increasingly recommended as an essential component of illness management. Patient is willing to start psychotherapy next week.

Substance Current Use:

CK denies any past or current substance abuse .

Medical History:

Two C sections birth of her children.

Family Substance Use and Psychiatric History

Reports maternal Grandmother had a history of depression. And her mother has Bipolar. Father has history of alcohol use disorder. Her brother smokes marijuana and was in jail for conduct disorder.


Social History

Single, patient has two children, but they have been taken away by CPS and given to her aunt. She lives alone in her apartment and works at a local Starbucks. She owns her car and has health insurance. Currently her aunt has her two small children. She is taking classes part time at a local college and had to withdraw her summer term due to her recent hospitalization. She intends on continuing college when her mood is more stable. She reports dating a new boyfriend.

Allergies: The client did not report any allergies.

Reproductive Hx: patient reports a history of two pregnancies and two births The patient’s last monthly periods were last week. She denies being pregnant and she reports being sexually active.

Review of Systems (ROS)

• General: Denies weight loss or gain, fever, or chills. Denies fatigue.

• HEENT: Head: Denies headaches, head injury/trauma. Eyes: Denies visual loss, double vision, or yellow sclera. Ears: Denies hearing loss, ringing in the ears, or drainage. Nose: Denies sneezing, congestion, runny nose. Throat Denies itching, swelling, redness, or sore throat.

• Skin: Denies lesions, rash, itching, or easy bruising.

• Cardiovascular: Denies chest pain, chest pressure, or discomfort. No edema or palpitations.

• RESPIRATORY: Denies shortness of breath, cough, or sputum.

• GASTROINTESTINAL: Denies anorexia, denies nausea, vomiting, or diarrhea. No abdominal pain or blood.

• GENITOURINARY: Denies burning on urination. Pregnancy. The last menstrual period was last week.

• NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Denies seizures activities

• MUSCULOSKELETAL: Denies any trauma, injury, or pain.

• HEMATOLOGIC: Denies any history of anemia, bleeding, or bruising.

• LYMPHATICS: Denies any enlarged nodes. Denies history of splenectomy.

PSYCHIATRIC: Reports Major Depressive Disorder (MDD) . Reports Bipolar Disorder. Reports being hospitalized last month for a severe manic episode. Stated had another manic episode in her teens.

• ENDOCRINOLOGIC: denies hypothyroidism. Denies hyperthyroidism Denies any history of sweating, cold, or heat intolerance. No polyuria or polydipsia or thyroid disorder. Denies any diabetes.


• Food: No food allergies.

• No Environmental and Seasonal Allergies.

• No Latex Allergy.


Physical Assessment:

• Vital Signs: not assessed

• General: She is alert and oriented and appears stated age. No weight loss or fever reported.

• Appearance: Normal appearance. She is well-developed. She is not diaphoretic.


• Head: Normocephalic and atraumatic.

Eyes: General: No scleral icterus. Right eye: No discharge. Left eye: No discharge.

Conjunctiva sclera: Conjunctivae normal. Nose: reports no drainage.

Neck: Normal range of motion.

Trachea: No tracheal deviation.

Cardiovascular: Rate and Rhythm: Normal rate.

Pulmonary: Pulmonary effort is normal. No respiratory distress.

Musculoskeletal: Normal range of motion.

Skin: General: Skin is warm and dry

Neurological: she is alert and oriented to person, place, and time.

Psychiatric: Attention and Perception: She appears attentive and alert and oriented.

Mood and Affect: Affect is flat and depressed.

Speech: Speech is clear.

Behavior: Behavior is calm.

Diagnostic results: There were no laboratory tests specific to diagnose BD. To diagnose BP. The PMHNP will conduct a thorough psychiatric history of the patient including family history as well as ask about current medical conditions that can affect the patient’s mood, I will order a urine drug screen because of my patient strong family history of use of alcohol and drugs. First, I will order CBC, chemistry profile , thyroid function tests, and B12 level to rule out metabolic causes or unidentified conditions . Johnson, Vanderhoef, & Johnson (2016). I will also order baseline EKG to make sure our patient does not have underling cardiac abnormalities before I order psychotropic medications. . There are diagnostic tools to assist in assessing for BD. Second, I will use the Mood Disorder Questionnaire to assess for bipolar disorder. Hirschfeld et al (2010) noted that The MDQ is a self-report inventory that screens for a lifetime history of a manic or hypomanic syndrome by including 13 yes ⁄no items (Question 1). In addition to achieving the threshold number of symptom items, the subject must also have indicated that the symptoms clustered in the same period (Question 2) and caused moderate or serious problems (Question 3) (16, 21, 22). An MDQ screening score of ‡ 7, plus concurrence of symptoms and at least moderate problems reported, was found to have a sensitivity of 29–91% and a specificity of 67–94% for the diagnosis of bipolar disorder. I will also use the DSM-5 to help me in diagnostic inclusions and exclusions for this client. (APA,2013).



Mental Status Examination:

CK is a 25-year-old African American female who looks her stated age. She is well-groomed and dressed appropriately. Her speech is appropriate for age, it is clear with normal rate and tone. She is cooperative with the interviewer. Her mood is depressed and labile, and her affect is flat. Her thought process is normal with concrete thinking. She does not have any delusions thoughts. She denies any auditory or visual hallucinations, she denies current suicidal or homicidal ideation. Her recent and remote memory is intact. She is oriented to time, place and person. Her concentration, judgment, and insight intact.

Diagnostic Impression:

· Bipolar I Disorder (Primary Diagnosis): According to DSM-5, our patient meets the following criteria of a manic episode: the patient had a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directly activity or energy, lasting at least a week and present most of the day, nearly every day( or any duration if hospitalization is necessary). (APA,2013). According to information obtained while interviewing the client, she has met the criteria to diagnose her with Bipolar I Disorder. She mentions that last month she experienced symptoms of mania that lasted a week and followed by period of depression. During the manic phase, our client reported that during that one week of manic phase, she reported increased energy and irritable mood and racing thoughts. Furthermore, she said during these episodes, she reported she was more pressured to keep talking, she had a reduced need for sleep, and reported sleeping only 3 hours at night during that time, she even noticed that during that time last month ,she went on reckless shopping sprees that she could not afford . Finally, the patient reported that her symptoms were so severe, she was anxious something was going to happen to her kids and her aunt took her kids while she was hospitalized.

Bipolar Disorder II- The diagnosis for Bipolar I and that of Bipolar II have many similarities in symptoms but they have subtle differences. The diagnosis of bipolar I require the presence of at least one manic episode, with or without a history of major depressive episodes, while bipolar II disorder requires at least one hypomanic and one major depressive episode. Datto, Pottorf, Feeley, LaPorte, & Liss. (2016). Furthermore, diagnosis of Bipolar I is differentiated from bipolar II disorder whether there has been presence of mania. (APA, 2013). Since the patient reported one episode of psychosis, it is safe to diagnose this client with bipolar I. Another key difference between the two is that bipolar I disorder does not have to have episodes of depression for a diagnosis, but it can, however bipolar II disorder must have at least one episode of major depression to justify a diagnosis (APA, 2013).

· Major Depressive Disorder (MDD): (APA, 2013) defined that MDD Diagnostic criteria include five or more symptoms, with at least one being depressed mood or loss of interest during the same two-week period. Other symptoms include significant weight loss or gain, or decrease/increase in appetite, insomnia or hypersomnia, psychomotor agitation, fatigue, feelings of worthlessness, diminished ability to think or concentrate, or recurrent thoughts of death, with all of them being nearly every day (APA, 2013). The client shared having symptoms of depression, such as depressed mood, diminished interest in normal activities, appetite changes, changes in sleep, loss of energy, and feelings of worthlessness after the episode of mania. The client in the video shared that her depressive symptoms lasted a week after her manic state. To diagnosed MDD, these symptoms must be present during the same 2-week period. In the case of our client, her symptoms changed from manic period to a depressive period, hence justifying the bipolar 1 diagnosis. Our client did not report 2 weeks of consecutive depressive periods.

Case Formulation and Treatment Plan:

The PMHNP will conduct a thorough psychiatric history of the patient including family history as well as ask about current medical conditions that can affect the patient’s mood. I will order a urine drug screen because my patient has strong family history of use of alcohol and drugs. I will order a CBC, chemistry profile, fasting lipid profile, thyroid function tests, and B12 level . I will also obtain the patient weight, and baseline history of personal and family history of diabetes, obesity and dyslipidemia before treatment with antipsychotics can cause weight gain. Stahl (2014).As part of his treatment, I suggest we included psychotherapy as an adjunct treatment to psychotropic medications. Swartz & Swanson (2014) noted that evidence demonstrates that bipolar disorder-specific psychotherapies, when added to medication for the treatment of the bipolar disorder, consistently show advantages over medication alone on measures of symptom burden and risk of relapse. One therapy that proved to be beneficial to bipolar patients is Cognitive Behavioral Therapy. In CBT the clients learn thought records, mood diaries, and activity scheduling, to modify automatic negative thoughts, remove distorted thinking, and interrupt cycles of mania and depression. Swartz, H & Swanson (2014). Chiang et Al ( 2017) noted that CBT is effective in decreasing the relapse rate and improving depressive symptoms, mania severity, and psychosocial functioning.

Medication treatment for our patient with bipolar 1 consist of Vraylar, a newer third generation antipsychotic medication that it is FDA approved for the treatment of acute mania, bipolar maintenance, bipolar depression, and other conditions. Vraylar is also described as a mood stabilizer. Stahl (2014). To promote good health, I will educate this patient about health promotions such as healthy eating, weight management and exercise to prevent weight gain since atypical antipsychotics medications such as Vraylar can cause weight gain. Stahl (2014). I will also educate patient on the following side effects: Lexapro can cause sexual dysfunction, decreased appetite, nausea, diarrhea, dry mouth. Vraylar can nausea, occasional vomiting, and weight gain). Stahl (2014).

An alternative treatment that can benefit patients with bipolar disorders is called Family Therapy. Family-focused therapy (FFT), as described by Miklowitz and colleagues, is a 21-session intervention that is conducted conjointly with a patient and family member (parent, sibling). Treatment focuses on psychoeducation, communication enhancement training, and problem-solving skills training. Swartz, & Swanson (2014). This approach is beneficial as it utilizes a team effort and involved the whole family in the support and treatment of the client. By learning about bipolar and obtaining the skills necessary to effectively interact with their family member during her manic or depressive states.

Risks and benefits of her prescribed medications are discussed including non- treatment. Informed client not to stop medication abruptly without discussing with providers. Instructed to call this clinic and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method and safe sex .

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Patient will continue taking Lexapro for depression and Vraylar for bipolar disorder. The patient was given referrals to a counselor for individual psychotherapy and patient was encouraged to take parenting classes since she mentioned being overwhelmed by taking care of her two children that are in her aunt custody. Patient was encouraged to follow up with social worker regarding her children living arrangements.

Client has emergency numbers: Emergency Services 911, Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal.

Reviewed hospital records/therapist records for collaborative information.

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. Patient verbalized understanding.

Follow up with PCP for routine checkups and wellness panel labs and informed patient to fax results to PMHNP .The rationale is to rule out other organic causes of mood disturbances. Patient educated and reminded to fast the night before for her lipid profile.

Patient educated to return to clinic in two weeks for continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care. The rationale for returning to clinic in two weeks to also monitor medications effectiveness and patient response to the treatment plan. Patient agrees to the plan and will return to clinic in two weeks.


As I continue to practice these SOAP notes, I am learning to critically think. For example, on my last SOAP note , I forgot crucial labs that are needed before initiating psychotropic medications. I am learning to think holistically about the patient. If I had to do this interview over, I would inquire more about the patient personal health history and medical conditions to rule out or treat any conditions that may contribute to current symptom manifestation. I will also make sure patient has a safety plan in place for those periods when she is vulnerable and manic. This is crucial since patient can be at increased risk of suicide .

3 Questions for Colleagues

· Question 1

Give one example of evidence based pharmacological or non-pharmacological treatment of bipolar 1 disorder. And advantages or disadvantages of proposed treatment.

· Question 2

What would you do differently if you were the PMHNP caring for this client?

· Question 3

What other safety considerations do we need while treating with patients with bipolar disorders.( related to medication, signs, and symptoms?


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders(5th ed.). Washington, DC: Author

Chiang, K. J., Tsai, J. C., Liu, D., Lin, C. H., Chiu, H. L., & Chou, K. R. (2017). Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PloS one12(5), e0176849.

Datto, C., Pottorf, W. J., Feeley, L., LaPorte, S., & Liss, C. (2016). Bipolar II compared with bipolar I disorder: baseline characteristics and treatment response to quetiapine in a pooled analysis of five placebo-controlled clinical trials of acute bipolar depression. Annals of general psychiatry, 15, 9.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University


Swartz, H. A., & Swanson, J. (2014). Psychotherapy for Bipolar Disorder in Adults: A Review of the Evidence. Focus (American Psychiatric Publishing), 12(3), 251–266.

Swartz, H. A., & Frank, E. (2001). Psychotherapy for bipolar depression: a phase-specific treatment strategy? Bipolar Disorders, 3(1), 11–22.

McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners27(9), 530–542.

Johnson, K., Vanderhoef, D., & Johnson, K. (2016). Psychiatric-mental health nurse practitioner. Silver Spring, MD: American Nurses Credentialing Center.