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Below is an attached case study. I just need two different responses from this case study and a atleast one reference for each of the responses. A response can just be just a paragraph.
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Week 7 Focused Soap Note
Christian O. Collazo
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
Robert Daun
1/9/24
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint): The patient was brought into the psychiatric clinic for a mental health
evaluation due to the patient complaining of experiencing instability in mood. PD endorses
extreme fluctuation moods, describing intense lows coupled with extreme highs. When asked
what that fluctuation in mood looks or feels like, pt. They expressed, “Sometimes I feel so
depressed I lose all desire to get involved with family events or school, and then sometimes I feel
full of energy and even get angry.” PD’s mother confirmed that he gets easily agitated and, at
times, has moments of sadness that appear as depression. The patient informed this writer that he
is concerned due to an increase in symptoms that have lasted more than six months, impacting
his quality of life.
HPI: PD is a 16-year-old Hispanic male grappling with intense mood swings between extreme
highs and crushing lows, often accompanied by excessive stress. The described emotional
rollercoaster has been overwhelming for PD, described as elevated stress levels amplified in the
fluctuations leading to moments of euphoria and periods of despair. The unpredictable emotional
instability has negatively impacted PD’s relationships, academic performance, and overall wellbeing. Unfortely, PD had sustained a manic episode that led to hospitalization at a local
behavioral health center to stabilize his current state. Per the patient’s history at the clinic, he
received an intramuscular injection of Aripiprazole (Abilify) for stabilization. PD endorses a
disruption in sleep patterns and loss of appetite, choosing to remain withdrawn and isolative
when hit with a depressed mood. PD currently denies SI/DTS/DTO, however, he has had
suicidal thoughts but no plans or intention to commit sucide.
Substance Current Use: Patient denies the use of illicit substances. Mother reports use of
vaping pens filled with nicotine and sometimes marijuana. Patient is not forthcoming when asked
regarding substance use and becomes defensive.
Medical History:
Current Medications: N/A
Allergies: NKDA
Reproductive Hx: N/A
ROS:
GENERAL: No fatigue or explained weight loss, no fever, or chills noted.
HEENT: No signs of impaired vision, eye pain, or yellow sclerae. Ears, nose, and throat: No
sore throat, runny nose, or hearing loss; no sneezing or congestion noted.
SKIN: No rash or irritation noted
CARDIOVASCULAR: Denies chest pain, pressure, or palpitations; no edema noted in
extremities.
RESPIRATORY: No productive or dry cough noted, no SOB or wheezing, clear lung sounds.
GASTROINTESTINAL: Denies nausea/vomiting or diarrhea, no constipation or abdominal
pain.
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
GENITOURINARY: Denies nausea/vomiting or diarrhea, no constipation or abdominal pain.
NEUROLOGICAL: Denies headaches; no tingling/numbness or ataxia noted. No changes in
bowel or bladder elimination.
MUSCULOSKELETAL: No muscle pain or back/joint pain noted. Full ROM in all
extremeties
HEMATOLOGIC: No bleeding, anemia, or bruising
LYMPHATICS: No abnormal findings
ENDOCRINOLOGIC: No abnormal findings
Objective:
Diagnostic results:
Blood work is not an indicator or actuary of detecting bipolar disorder. A proper medical history
and background can aid in detecting potential contributing factors that lead to an accurate
diagnosis.
MRI – Utilizing an MRI as an identifying tool can aid the mental health provider in ruling out
abnormal brain structures and potentially compromised adjacent organs.
Assessment:
Mental Status Examination:
Diagnostic Impression:
Bipolar I Disorder: According to the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) defines bipolar I disorder as at least one manic episode. Manic episodes are displayed
with abnormal elevated and irritable mood fluctuations accompanied by an increase in energy or
activity behavior.
Differential Diagnosis:
1.
Major Depressive Disorder – Adolescents may initially present with a form of depressive
symptoms during episodes. As a mental health provider, being able to distinguish major
depressive disorder from BP is critical in the proper treatment of established mood disorders.
2.
Attention-Deficit Hyperactivity Disorder (ADHD) – Hyperactivity and impulsive
behavior can resemble manic episodes in a patient with Bipolar Disorder. Properly assessing the
frequency of onset symptoms is vital in determining an appropriate diagnosis.
3.
Borderline Personality Disorder (BPD) – Impulsive behavior and actions of instability are
often present in BPD, which can be comparable to Bipolar Disorder. PMHNPs differentiate
between the two potential diagnoses to provide evidence-based practice and treatment.
Reflections:
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Reflecting on this encounter with PD, I agree with my clinical preceptor that this patient suffers
from bipolar symptoms of mania and depression, leading to a diagnosis of F31.9 Bipolar
Disorder, unspecified, as this patient displayed these symptoms for a prolonged period extending
longer than six months. As a future PMHNP, obtaining a proper historical background, current
behavior, and previous treatment is critically important to identify markers that lead to future
evidence-based treatment.
Case Formulation and Treatment Plan:
PD’s tailored treatment plan structured for the diagnosis of F31.9, Bipolar Disorder, unspecified,
will consist of the introduction of cognitive behavior therapy and mental health medication.
Introducing PD to medication will aid in stabilizing the symptoms that cause fluctuations in his
mood. Lithium 300mg 1 tab PO TID. The starting dose of lithium in Arms II and III was 300 mg
thrice daily (Findling et al., 2022). The study above supports the psychopharmacology strategies
that helped me establish the patient’s treatment. The patient was provided with information
regarding the importance of medication adherence to aid with the onset of the symptoms
mentioned above. Young people with Bipolar Disorder exhibit poor medication adherence when
measured objectively, yet they, their parents, and treating physicians report nonadherence
(Goldstein et al., 2016). Information on the increased health risk associated with the use of
vaping (e-cigarettes) and marijuana was provided to patient. According to Tobore, TO (2019),
Electronic cigarettes have been connected with increased impulsivity, with one animal study
demonstrating that exposure to e-cigarette vapor during times of rapid brain growth (like during
adolescence) can cause hyperactivity and impulsive behavior changes. Even though the patient
was apprehensive regarding the use of e-cigarettes and marijuana, education was provided due to
concerns and information provided by the mother. Another study looking specifically at the teen
population found increased risks of physical fighting, attempted suicide, and alcohol/marijuana
use when comparing non-users to teens who smoked or vaped. Another study looking
specifically at the teen population found increased risks of physical fighting, attempted suicide,
and alcohol/marijuana use when comparing non-users to teens who smoked or vaped (Demissie
et al., 2017).
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at
their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
01/09/2024
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
References
American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders:
DSM-5, Fifth edit. Washington, DC (2013). 10.1176/appi.books.9780890425596
Demissie Z, Jones SE, Clayton HB, King BA. Adolescent Risk Behaviors and Use of Electronic
Vapor Products and Cigarettes. Pediatrics. 2017;139(2) doi: 10.1542/peds.2016-2921.
Findling RL, Kafantaris V, Pavuluri M, McNamara NK, McClellan J, Frazier JA, Sikich L,
Kowatch R, Lingler J, Faber J, Rowles BM, Clemons TE, Taylor-Zapata P. Dosing
strategies for lithium monotherapy in children and adolescents with bipolar I disorder. J
Child Adolesc Psychopharmacol. 2020 Jun;21(3):195-205. doi: 10.1089/cap.2010.0084.
PMID: 21663422; PMCID: PMC3111866.
Goldstein TR, Krantz M, Merranko J, Garcia M, Sobel L, Rodriguez C, Douaihy A, Axelson D,
Birmaher B. Medication Adherence Among Adolescents with Bipolar Disorder. J Child
Adolesc Psychopharmacol. 2016 Dec;26(10):864-872. doi: 10.1089/cap.2016.0030.
Epub 2016 Jul 15. PMID: 27419273; PMCID: PMC5178003.
Tobore TO. On the potential harmful effects of E-Cigarettes (EC) on the developing brain: The
relationship between vaping-induced oxidative stress and adolescent/young adults social
maladjustment. Journal of Adolescence.
2019;76:202–209. doi: 10.1016/j.adolescence.2019.09.004.
© 2022 Walden University
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