Case study on a mental health child is attached. Highlighted portions are needed to be complete * please list 3 differential diagnoses according to DMS-TR5 * references are to be 3 years or less

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

Week 9: Focused Soap Note and Patient Case Presentation

Shannon Pierce

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan I

Dr. Judith Gichia-Waldrop

April 25, 2024

Subjective:

CC “ I’m not sure what is going on with me. Talking about my issues does no good. No one ever listens or seems to understand nor can they help me.”

HPI: VJP is a 17 years old black male who presents for medication management and assistance with mental illness due to impulsive, defiant behaviors. VJP has never bee hospitalized but has seen a psychiatrist since age two (2). VJP has issues with aggression and impulsive behaviors. Has been known to rin away from home but never missing for longer than 24 hours. VJP has been on a trail of medications to include Clonidine, Wellbutrin, Depakote, Intunive, Concerta and last trial on Focalin. VJP felt medication made him “too mellow” and he was tired of people asking was he “OK”. VJP and his mother decided to end his treatment with Dr. A for they felt his symptoms had improved as well as his teachers. VJP was diagnosed with ADHD, ODD, Dysfunctional Mood Disorder, anxiety and major depression. Recently, VJP has been acting out and becoming more defiant than usual. A life changing event that has taken place is VJP mother revealing that she is dating a woman and that she has been attracted to woman for years but afraid to express her feelings. VJP has become recentful towards his mother to the point where he has moved out and now living with granparents. VJP has increased his use in substance abuse to contain vaping and marijuana daily. He denies any alcohol use. He denies trouble sleeping. He finds himself very irritale and hard to control his temper. Currently denies SI/HI and no hallucinations, although he does wish he ”was not around anymore”

Substance Current Use: vaping and consumption of marijuana daily. No alcohol use

Medical History:

Current Medications: currently on no medications
Allergies: NKDA
Reproductive Hx: denies being sexually active

ROS:

GENERAL: no fever, chills, or fatigue. Has a recent weight loss of over 100 kbs within the last year
HEENT: Eyes: no blurred vision or visual loss. Wear glasses at times. Ear: no drainage or tinnitus, no difficulty hearing. Nose: no drainage, no sneezing or runny nose. Throat: no sore throat and no difficulty swallowing
SKIN: no open wounds, no dryness, tattoos noted to upper bilateral arms
CARDIOVASCULAR: no chest pain, palpations, no irregular heart beat, no edema
RESPIRATORY: no shortness of breath, cough
GASTROINTESTINAL: no N/V/D, no abdominal pain, bowel regular
GENITOURINARY: no burning on urination, hesitancy, blood and no odor or abnormal color
NEUROLOGICAL: no numbness, tingling, ataxia. Does report frequent headaches
MUSCULOSKELETAL: no muscle, back or joint pain and no stiffness
HEMATOLOGIC: no bleeding or brusing
LYMPHATICS: no enlarged lynph nodes
ENDOCRINOLOGIC: no sweating, reports cold intolerance but contributes this to weigh loss

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: He is a 17 years old black male who presents his stated age. He is hesitant to answer question but is complaint and will take a few minute to respond. He is neatly dessed, weather appropriate and noted to have long locs. No evidence of abnormal motor activities. Speech is clear and coherent, noted to be pressured at times. Voice will range from high to low and fast spoken when getting irritable. His thought process is goal directed and somewhat logical. No evidence of flights of ideas. His mood id labile. He has a flat affect, appropriate for current mood. He denies any auditory or visiaul hallucinations. He currently denies any suicidal or homicidal ideations but does states, “ wish he was not around anymore.” His recent and remote memory is intact. Figiidty as he sits during assessment. Easily distracted but can be redirected. His insight is fair with poor judgement.

Diagnostic Impression: You must begin to narrow your differential diagnosis to your

diagnostic impression. You must explain how and why (your rationale) you ruled out

any of your differential diagnoses. You must explain how and why (your rationale) you

concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives

for the specific patient case.

Reflections: Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently? Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.)

Case Formulation and Treatment Plan:

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document? Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call 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 (exclude for males). 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. Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist): Client was encouraged to continue with case management and/or therapy services (if not provided by you). Client has emergencynumbers: Emergency Services 911, the Client's Crisis Line 1- 800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them) Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed) 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. (this relates to informed consent; you will need to assess their understanding and agreement) Follow up with PCP as needed and/or for: Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education) Return to clinic: Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care. References (move to begin on next page) You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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: ________________________

References