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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


Student Notes

Patient is a 68yo F with PPHx. of Schizoaffective disorder and stimulant (cocaine) use disorder and PMHx. of HTN, CKD, anemia, Afib who presents to crisis under PC after ingesting unknown number of pills and endorsing suicidal thoughts. Patient is hostile, uncooperative, restless and irritable during interview; history limited due to irritability. Patient endorses having taken an unknown number of pills, cannot recall the name of the pills with the intention to “hurt [herself]”. Patient states she has had suicidal ideations chronically, from “years ago”. Patient denies past suicidal attempts and history of self-injurious behavior. She also denies symptoms of depression such as anhedonia, low energy, sleep disturbances and difficulty concentrating. Patient denies homicidal ideation. Patient endorses persecutory delusions and auditory hallucinations although she is unable to further elaborate on their content. Patient endorses crack cocaine use with last use being 2 days ago, she cannot tell the amount consumed. She denies use of other illicit drugs including alcohol. UTOX positive for cocaine and metabolites. Patient endorses medication non-adherence and is currently homeless. Cocaine use disorder (ICD10-CM F14.10, Discharge, Medical) *Probable Unspecified mood [affective] disorder (ICD10-CM F39, Discharge, Medical) *Probable Acute psychosis (ICD10-CM F23, Discharge, Medical) Plan: -Admit to Inpatient, Involuntary -Meds: -Psychotropic: ETOs only -Medical: Seroquel 50mg BID, Remeron 15mg, QHS, QHS -Labs: -Safety: No 1:1 sitter acutely indicated at this time. Continue current level of inpatient staff observation. Discussed with team and will continue to monitor and treat as indicated.

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