Week 3: Focused SOAP Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan 2 Practicum
September 19, 2021
Introduction
Each mental intervention is based on the evidence gathered during the initial interview
with the patient; each patient's therapy begins with a thorough medical and mental health
evaluation, the incorporation of trust, and a dialogue of past mental health history, substance
misuse history, family mental health history, and so forth. The evaluation of the patient in this
case was documented, and a diagnostic impression was formed based on the information
obtained from the patient during the evaluation. A therapy strategy was devised when the case
was developed. The patient is a 7-year-old Caucasian boy who was scheduled for an initial
screening for a mood disorder after her pediatrician recommended that she consult a psychiatrist.
At this time, the patient is not taking any medications. DDAVP PO was given to the patient, but
it was stopped since it was ineffective.
Patient Initial: R.C Age: 7 Gender: Male
Subjective Data:
CC: “My mother said you will be able to help me with my mood problem”
HPI: R.C a 7-year-old White male who was referred to a psychiatrist for evaluation after several
treatments and efforts by his teacher to help him with his mood. According to patient's
mother during the interview, the mother said that the pediatrician placed patient on DDAVP
which did not help patient. Mother did not list dose of medication or frequency. During the
interview, patient states that he feels worried most time. Patient said ” I am worried about
everything”. Patient admits to bad dreams and that he dreams a lot that he can't find his brother
and mom. When asked if patient feels lost. Patient responding saying ” I worry about my mom
and brother when I am alone”. Patient went further to state “People in school don't like me. They
call me smelly and calls me names”. Patient said that his mom said his school mates calls him
those names because patient does not take her baths. Patient expressed that he is sad about
it. Patient said sometimes he will have accidents at night. Patient also states that his school
mates his school mates don't know how it feels when your father can't come back home and that
he worried what if his mom does not come home. Patient states that his teacher also picks on him
in class. His teacher was telling him to sit down and focus. Patients admit to harming other by
saying” I have thrown book at Billy”. Denies ever causing harm to himself or any intention to
harm himself.
When the mother was interviewed, the mother expressed her concern that patient is
anxious and worry about silly things like his is going to die, that the mom loves his brother more
than she loves him, that the mom won't pick him up in school. Mother expressed that he has a
difficult time going to sleep, learning difficulty, gets in trouble in school, throws things around
the house, wants his light on at night and doors open, has difficult time going to sleep, claims
stomach upset just to be sent home from school, almost daily. He won't eat and has lost some
weight. lost 3 pounds in the last 3 weeks. Mother explained that he wets the bed at night. That
the pediatrician referred them to the Psychiatrist and has prescribed him DDVAP, but the
medication doesn't seem to help. Mother expressed that Rev father was killed in the war but she
thought Rev was too young to know about death, so she didn't tell him his father is late. Mother
feels guilty about not disclosing the death of Rev's father to him and said it was all her fault that
Rev functions this way.
Substance Use History: denies substance use or anyone using substance at home.
Family Psychiatric/Mental/Substance Use History: Patient father had Hypertensin. Patient’s
mother: Anxiety. Brother: Asthma, ADHD and Anxiety. Grandfather: Diabetes and cancer.
Grandmother: Heart disease.
Psychosocial History: Patient lives with mother, little brother and his puppy. Father is deceased.
Both parents are Caucasian. Patient is presently finding difficult to keep friends in school.
Educational Level: Patient is in Middle school. Legal history: No legal history.
Psychiatric History: None
Medical History/Surgical History: Bedwetting
Birth and Developmental history: Vagina birth with no complications. Patient met all
developmental millstones on time.
Current Medications: No current prescribed medication or OTC. Patient was once placed on
DDAVP.
Allergies: NKDA or seasonal allergies
Reproductive Hx: Patient denies sexual history or abuse
APPEARANCE: Dressed appropriately and well groomed
HEENT: No vision problem. Ears normal shape with no discharges. Nose normal shape; no
deviation or drainage. No sore throat or swelling around the neck.
CV: no cardiovascular abnormality
PULMO: Lungs sounds clear and no adventitious lung sounds
ABDOMEN: All bowel sounds on all four quadrant
GENITOURINARY: No disorder or problem with this system
EXTREM: All extremities is moveable; some tremors noted in upper extremities
NEURO: alert and oriented to person, place, time, and situation but very unrest
SKIN: Skin intact and appropriate; no rash or lesion noted
Physical exam:
Vital Signs: none at this time
Weight: 51Ibs
Height: 4 ft
Diagnostic results:
PHQ 9: Scored 13
GAD 7: scored 10
Objective:
Diagnostic results: no diagnostic test ordered or required at this time
Assessment:
Mental Status Examination
Patient appeared stated age, no apparent distress on arrival and during the session. Patient and
baby appears well nourished, well groomed. Well dressed and clean. Patient was cooperative, not
fidgeting, makes good eye contact and able to sit still. Patient appears to be anxious and worried
Affect was full range, somewhat constricted and often sad. Able to stay still. No abnormal
movement noted. Gait steady and posture upright. Patient was coherent but not very logical due
to worry. No acute psychosis or mood symptoms. No delusions or paranoid
behavior noted. Patient has some intrusive thoughts. Patient’s speech was normal rate, rhythm
volume and clear. Patient does not feel like she will get better. She had a good judgment and
recognized what she needs to be done to care for her baby. Patient was attentive to the provider
and attentive to the baby’s needs while she learn. Alert and oriented times 4. Memory both long
and short term was intact. Patient denies suicide ideation. Patient admits having intrusive
thoughts of hurting baby but patient finds this thoughts upsetting and denies intent. Patient states
she removes herself in situation that can cause harm to baby.
Differential Diagnoses
Adjustment Disorder: “Adjustment disorder is a maladaptive response to recognized
psychosocial stressors or life changes that is characterized by obsession with the stressor and
failure to adapt.” Within three months of the initiation of a specific stressor, disorder is defined
as the appearance of emotional or behavioral symptoms in reaction to the stressor. Adjustment
can result from expected or unexpected events, and it can lead to disorder, causing an individual
to feel confused, worried, anxious and disoriented (disoriented), preventing him from going
about his normal routine. Separation, dissolution of marriage, the termination of a long-term
relationship unexpected death of a loved one, the loss of a career, being cheated on by a partner
or spouse, being the victim of a sexual assault are all examples of stressful events that can result
to adjustment disorder. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) must be completed within three months after the commencement of the stressor or
stressors. In addition, one or both of the following conditions must be fulfilled: Clinically
significant distress is defined as distress that is out of proportion to the predicted stressor
reactions and symptoms. They cause a lot of pain and make it difficult to function (American
Psychiatric Association, 2013).
Generalized Anxiety Disorder: Excessive anxiety and worry regarding a number of events or
activities, happening more days than not for at least 6 months (such as work or school
performance). GAD (generalized anxiety disorder) is a mental health issue that affects both
children and adolescents. A youngster with GAD experiences a lot of worry and terror for no
apparent reason. Worry may be excessive in comparison to the situation. Physical appearance,
prior habits, social acceptance, family difficulties, failing to fulfill parents' expectations, personal
abilities, and academic success are all common concerns for children and teens with GAD.
Generalized Anxiety Disorder is a natural stress response that, in certain cases, can be beneficial.
It can alert us to potential risks and help us plan and pay attention. Excessive dread or anxiety
characterizes anxiety disorders, as opposed to normal feelings of apprehension or anxiety.
Anxiety disorders are the most prevalent mental illnesses, affecting almost one-third of all adults
at some point in their lives. Diagnostic Criteria for Generalized Anxiety Disorder (GAD) in the
DSM-5: Excessive anxiety and worry (apprehensive expectancy) about a number of events or
activities, occurring more days than not for at least 6 months (such as work or school
performance), the individual has difficulty controlling his or her anxiety, and three (or more) of
the following six symptoms are linked to anxiety and worry: Being easily fatigued, having
difficulty concentrating, or having your mind go blank are all indicators of restlessness or
agitation. Irritability manifests itself in the form of irritability, muscle tension, and sleep
difficulties (American Psychiatric Association, 2013).
Dysthymic Disorder: Depressed mood for most of the day, for more days than not, as indicated
by subjective account or observation by others, for at least 2 years. Presence while depressed of
two or more of the following: Poor appetite or overeating, insomnia or hypersomnia, low energy
or fatigue, low self-esteem, poor concentration or difficulty making decision, feelings of
hopelessness. The disturbance is not caused by a substance's direct physiological effects (e.g., a
drug of abuse or a medicine) or a general medical condition. Clinically substantial distress or
impairment in crucial areas of functioning are caused by the symptoms. Although dysthymia was
once thought to be less severe than major depression, its implications are now widely
acknowledged to be serious, including significant functional impairment, increased morbidity
from physical disease, and an increased risk of suicide.
To determine a diagnosis of Dysthymic Disorder, the DSM-5 provides the following criteria.
During the 2 years period, the person must have five or more symptoms, with at least one of
them being either (1) sad mood or (2) lack of interest or pleasure. Changes in energy level,
depressed mood most of the day, nearly every day, decrease or increase in appetite nearly every
day, poor self-esteem, anxiety, isolation, appetite change, forgetfulness, not completing assigned
chores at work or school, guilt, and loss of energy are all listed in the DSM-5 (American
Psychiatric Association, 2013).
Reflection
Every mental intervention is determined by the information collected during the initial
conversation with the client; every client's therapy starts with a comprehensive medical and
behavioral health examination, the creation of trust, and a discussion of previous mental health
history, substance abuse history, family mental health history, and so on. Individuals with whom
they had connections that comprised effective communication, cultural awareness, and the
absence of compulsion were considered as trustworthy (Sadock et al., 2014). One thing I might
have done differently as a PMHNP is to meet the patient first, establish a therapeutic
relationship, ask the young patient about his relationship with his parents, and then ask questions
unrelated to the scheduled visit, which would help to create a welcoming atmosphere. Ask open-
ended inquiries on the patient's personality, ailment, or personality without appearing to have a
bias. Inquire about the patient's sexual orientation and preferred method of communication.
Cultural competency includes elements such as trust, respect for diversity, respect for religion,
equity, fairness, and social justice, which must all be considered during any interview or
encounter between a healthcare practitioner and a patient (Sadock et al., 2014). When I interview
a patient about their mental illness symptoms, I look at how they look, speak, and act to
determine if there are any clues that could explain their symptoms.
Case Formulation and Treatment Plan
The patient will begin individual supportive therapy then advance to family and peer
group supportive therapy depending on level of improvement. The patient’s mother will receive
an educational pamphlet, as well as assignments and a follow-up consultation, on themes that
will aid in the healing and coping process.
Patient will be started on fluoxetine (Prozac). An initial dose of 10 mg/day then increased
to 20 mg/day after 1 week. Education and side effects of medication was provided for mother
and son.
Bedwetting can be avoided by limiting how much a child drinks in the evening, avoiding
caffeinated meals and beverages, and promoting regular toilet usage throughout the day. Mother
was told to wake the patient up at night to urinate and to make sure the patient's clothing were
changed before going to school in the morning. Personal hygiene assistance should be provided
to the patient.
In case of emergency, the provider provided patient with helpful phone numbers: 911 for
emergencies and the Client's Crisis Line. Reports from doctors and therapists were evaluated for
mutual and collaborative understanding and for continuity of care.
Patient’s mother was educated and was advised to call their primary care physician or go
to the nearest emergency department if they had any questions or concerns about the
development of any undesirable or unexpected outcome or side effects.
Every 30 days, patient must return to psych tele-appointments for continuity of care and
for provider to monitor progress and outcome of treatment but patient will return a week after
starting Prozac for adjustment of dosing and to monitor improvement.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders, fifth edition DSM-5 American Psychiatric Association, 2013.
Bachem, R., & Casey, P. (2018). Adjustment disorder: A diagnosis whose time has come.
Journal of Affective Disorders, 227, 243-253. https://doi.org/10.1016/j.jad.2017.10.034
Sadock, B.J., Sadock, V.A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11 th ed.). Philadelphia, PA: Wolters Kluwer.
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A.
(Eds.).
(2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley
Blackwell.
Walden University. (2021). Case study: Dev Cordoba. Walden University
Blackboard.
https://class.waldenu.edu
