NRNP 6665 PMHNP Care Across the Lifespan INRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psych

NRNP 6665 PMHNP Care Across the Lifespan I

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

Name: P.P                DOB: 1/07/1995 Age: 25 yrs Gender: female 

Subjective:

CC (chief complaint): mood cycles between periods of low energy for about 4 to 5 times in a year, and mostly being high for more than a week in a row.

HPI: the patient came for a mental health assessment, and seeking review of her medications after being treated for previous psychiatric symptoms and being started on medications. She has a history of being treated using medications such as Zoloft, Risperidone, Seroquel (quetiapine), and Clonazepam, then stopping due to side effects. She reports getting episodes of low energy, no motivation, disinterest in activities 4 to 5 times a year. During these low periods, she often skips work, and eats too much, and prefers to sleep mostly up to 12 to 16 hours a day. She reports having periods that she is high for over a week, whereby she sometimes has auditory hallucinations. Excessive talking, insomnia for days, increased goal-orientedness, and heightened sexual behavior. The conversation also revealed she has grandiosity and a heightened sense of importance whereby she envisions everything about her future being with celebrity stars.

Past Psychiatric History: history of several admissions or psychiatric symptoms, she has had no suicidal or homicidal ideation since 2017.

Family Psychiatric History: her mother suffered from a psychiatric illness which she thinks was either bipolar and she tried committing suicide once. Her father went to prison for drugs and thinks her brother probably also has been diagnosed with a psychiatric problem before.

Legal History: she has been arrested once for public disturbance, but thinks this was made up because she cannot remember that scene

Substance Current Use: she smokes one packet of cigarettes daily, and has no recent history of other prescription drugs or substance abuse.

Medical History: he has hypothyroidism and polycystic ovarian syndrome (PCOS)

•       Current Medications: takes thyroxines for hypothyroidism and oral contraceptive pills for PCOS
•       Allergies:no known food or drug allergies.

• Reproductive Hx: heterosexual female but has a heightened sexual life at different times which places her at high risk.

Review of systems (ROS):

• GENERAL: no fever, night sweats, or vomiting, but amidst to have gained weight when taking some psychotropic medications
• HEENT: no changes in visual acuity, no diplopia, eye discharge, or photophobia. She has no ear pain, tinnitus, or discharge. No history of nose bleeding, recurrent upper airway infections, she has no denture or teeth problems, and reports of good oral hygiene.
• SKIN: normal hair texture and pigmentation, no nodules, ulcers, or lesions.
• CARDIOVASCULAR: she has no paroxysmal nocturnal dyspnea, intermittent claudication, palpitations or chest pain.
• RESPIRATORY: no exertion or difficulty in breathing, hemoptysis, or coughing.
• GASTROINTESTINAL: she has a good appetite, no changes in bowel habits, no nausea, vomiting, heartburn, dysphagia, yellowness of eyes, or abdominal pain.
• GENITOURINARY: no urinary urgency, incontinence, hematuria, frequency, hesitancy, dysuria, color changes, or decreased urine output.
• NEUROLOGICAL: No changes in memory, convulsions, syncope, lightheadedness, abnormal sensations, or dizziness.
• MUSCULOSKELETAL: no changes in gait or mobility, no joint aches, swelling, fractures, or history of arthritis or gout.
• HEMATOLOGIC: no bloody or dark stool, no easy bruising, or nosebleeding.
• LYMPHATICS: no peripheral edema, or swellings
• ENDOCRINOLOGIC: she has no polyuria, polydipsia, or constant polyphagia. She, however, reports slowness and a history of current treatment for hypothyroidism.

Objective:

Physical Exam 

General: He was well-groomed, seemed overweight, and normal gait.

Vital signs: BP 123/78; pulse 81 regularly regular, temperature 37.5 ear; RR 21; weight: 142lbs; height 5’2; BMI 26 (overweight).

The rest of the systemic examination was normal. 

Diagnostic results: awaiting results of her lipid profile.

Assessment:

Mental Status Examination: 

Appearance: looked like a young adult, and as she walked in she responded to my greetings and sat with normal posture. She was well dressed, despite having the smell of cigarettes she did not look intoxicated. she had no obvious bruises or body scars on exposed areas.

Level of consciousness and Orientation: she was alert and well orientated to time and place, and person.

Behavior: she was charming, had good rapport and attitude despite getting irritable on few occasions, and being too critical of personal questions. However, she was cooperative on kind assurance, with no abnormal movement or compulsions, and didn’t resist being examined.

Concentration and attention: she maintained normal eye contact, and was attentive throughout the assessment.

Speech: her speech was not pressured, with normal volume and tone, with a short latency of speech. She responded to questions adequately, despite admitting to having a history of excessive talking. Mood: currently has a normal mood she often feels high “keep my moods high, high, high”, but also sometimes gets depressed “I feel like I’m not worth anything”

Affect: neutral Appropriate to content and congruent with the mood.

Thought Process: she expressed herself in a logical and meaningful manner. She had no circumstantiality, tangentiality, or flight of ideas, she had no neologisms or thought blocking.

Thought content: she has ideas of grandeur, and pseudo-delusional conviction of importance, but no poverty of thought, and no suicidal and homicidal ideation. She has no phobias or irrational fears, no obsessions or compulsions.

Perceptual Disturbances: she has auditory hallucinations, no illusions, and no episodes of depersonalization or derealization.

Cognition: her Immediate, short-term, and long-term memory were intact. She had good attention, judgment, abstraction, and level 6 insight.

Diagnostic Impression: Bipolar 1 Disorder. 

The patient was otherwise normal on this visit since the mental status examination only tells about the mental status at that moment, but can change at any time. The presenting complaints and information gathered on a further inquiry made me arrive at a primary diagnosis of bipolar 1 disorder. According to Ganti et al., (2018), Bipolar I disorder is diagnosed when one meets the criteria for a full manic episode with or without episodes of major depression, thus also called manic-depression. Often patients have interspersed euthymia, major depressive episodes, or hypomanic episodes between manic episodes (Perrotta, 2019), of which she presented in a euthymic state on this visit. She is mostly in the manic phase due to undertreatment (López-Muñoz et al., 2018), since the euphoria, heightened energy, and goal-orientedness make her skip her medications.

Differential diagnoses: 

Schizoaffective disorder: patients with this disorder, often meet criteria for either a major depressive or manic episode during which psychotic symptoms such as hallucinations and delusions consistent with schizophrenia are also met. Additionally, mood symptoms present for a majority of the psychotic illnesses since some may have atypical features such as flat or blunted affect, anhedonia, apathy, and lack of interest in socialization (Ganti et al., 2018). As such patients often cycle between having a diagnosis between psychotic and mood disorders, thus are given the second generation. antipsychotics such as risperidone to target both psychotic and mood symptoms.

Organic mood disorder due to hypothyroidism: psychiatric symptoms may also be a manifestation of organic disorders such as endocrine or metabolic disorders. Additionally, patients with bipolar also have a high prevalence of psychiatric and medical comorbidities (Grande et al., 2016), such as thyroid disorders or diabetes. She admits to having comorbid hypothyroidism, which could explain the episodes of depression due to undertreatment since she has a history of skipping other medications.

Seasonal affective disorder: This condition is often described as a subtype of recurrent depressive or bipolar disorder. Often patients have recurrent dysregulated mood and affective episodes of regular onset and remission of similar times annually (Pjrek et al., 2016). This condition has been shown to have a high degree of persistence and only about 20 percent of patients get to complete remission after five to eleven years (Nussbaumer-Streit et al., 2018). This is less probable because she described manic symptoms that lasted more than a week (Ganti et al., 2018), thus meeting the criteria for a manic episode.

Case Formulation: this case involves P.P, who is a 25-year-old female with comorbid hypothyroidism and PCOS. Despite having major depressive episodes, where she has anhedonia, hypersomnia, depressed mood, feelings of worthlessness, slowness, loss of energy, and excessive eating, she also experiences manic episodes consisting of grandiosity, inflated self-esteem, increased goal-orientedness, decreased need for sleep, and talkativeness, and excessive involvement in sexual indiscretions despite its negative consequences.

Treatment Plan: most psychiatric conditions require both pharmacotherapy and psychotherapy to have good outcomes. Bipolar patients benefit from mood stabilizers such as lithium, which has been shown to reduce mania and suicide risk, or carbamazepine, especially if the symptoms are rapidly cycling. Most patients have a faster response when mood stabilizers are combined with atypical antipsychotics such as risperidone and quetiapine. Antidepressants are discouraged as monotherapy due to concerns of activating mania or hypomania. I would start her on carbamazepine, at an Initial dose of 200 mg PO q12hr, since it is easier to monitor and make adjustments unlike lithium (Arcangelo et al., 2017). Additionally, I would recommend her to start on Supportive individual therapy, then later enlist her into group therapy to help prolong remission once the acute manic episode has been controlled. I would encourage her to start thinking of quitting smoking and weight reduction since they negatively affect her health.

Reflection notes:

This patient presented minimal challenges since she had good insight into her psychiatric problem. Otherwise, I think I would have explored more on how the symptom cycle between mania and depression and the periods of these symptoms. Additionally asking more about psychotic symptoms such as illusion and delusions would help make a clearer diagnosis with specifiers. If this patient becomes difficult to follow up I would consider referring her to a psychiatrist, and an addiction and wellness counselor

References

• Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. (2017). Pharmacotherapeutics for Advanced Practice (Vol. 4). Philadelphia: Wolters Kluwer.
• Ganti, L. K. (2018). First aid for the psychiatry clerkship. McGraw Hill Professional.
• Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The Lancet, 387(10027), 1561-1572. https://doi.org/10.1016/s0140-6736(15)00241-x
• López-Muñoz, F., Shen, W. W., D’ocon, P., Romero, A., & Álamo, C. (2018). A history of the pharmacological treatment of bipolar disorder. International Journal of Molecular Sciences, 19(7), 2143. https://dx.doi.org/10.3390%2Fijms19072143
• Nussbaumer-Streit, B., Pjrek, E., Kien, C., Gartlehner, G., Bartova, L., Friedrich, M. E., Kasper, S. & Winkler, D. (2018). Implementing prevention of seasonal affective disorder from patients’ and physicians’ perspectives–a qualitative study. BMC Psychiatry, 18(1), 1-10. https://doi.org/10.1186/s12888-018-1951-0
• Perrotta, G. (2019). Bipolar disorder: definition, differential diagnosis, clinical contexts, and therapeutic approaches. Journal of Neuroscience and Neurological Surgery, 5(1), 1-6. DOI: 10.31579/2578-8868/097
• Pjrek, E., Baldinger-Melich, P., Spies, M., Papageorgiou, K., Kasper, S., & Winkler, D. (2016). Epidemiology and socioeconomic impact of seasonal affective disorder in Austria. European Psychiatry, 32, 28-33. https://doi.org/10.1016/j.eurpsy.2015.11.001

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