Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their paper presentations. You may also provide additional information, alternative points of view, research to sup

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

Week (#4): (COMPLEX STUDY CASE PRESENTATION)

David Henry

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Professor Janaya Evenson

June 19th, 2024

Subjective:

CC (chief complaint): “ I think my depression has been getting worse “

HPI: Patient is a 17 year old biological female that identifies as a transgender male and wants to be addressed as a boy. Client reports feeling more depressed and things have been getting worse with patient endorsing having poor sleep, crying spells, low energy/motivation, irritability and anxiety attacks. Expressed experiencing social anxiety when having to present in class, which has led the patient to missing school several times over the last few weeks of. Endorsed that depressive symptoms was triggered by friends who patient believes are unreasonable with him and his partner and have stopped talking to the patient and has been blocked on social media. Stigma, discrimination, and tensions within families, and with peers, appear to contribute to internal distress which may then relate to self-harming and suicidal actions (Goldblatt et al., 2024). The patient who is in therapy reports that some coping skills learned have helped the patient a little but relies on journaling to try and manage stressors. Patient is with a history of self-harm with self inflicted cuts to arm and banging head on walls that hadn’t happened in over three months. Collateral information provided by mother who initially brought patient in for an evaluation reports that the patient becomes irritable when told what to do but has not been violent towards mother. Mother who is being treated for depression and anxiety believes that her son is exhibiting behaviors that mother was dealng with. Per mother, patient is in bed sleeping in a dark room, no motivation, guarded with a poor appetite. Patient is medication compliant with no reports of AH/VH, no SI/HI, no plans for self harm and is denying mania/hypomania.

Past Psychiatric History:

General Statement: Patient endorsed being diagnosed with depression 4 months ago and is with increased risky behavior and self harm.
Caregivers: Not Applicable
Hospitalizations: No prior hospitalization
Medication trials: No previous medication trials.
Psychotherapy or Previous Psychiatric Diagnosis: Diagnosed with depression four months ago and anxiety over a year ago.

Substance Current Use: Denies use of cigarettes, alcohol, cannabis, or illicit drugs. No treatment for any substance abuse.

Family Psychiatric/Substance Use History: Mom is with history of depression and anxiety with Wellbutrin being prescribed for treatment of diagnosis. Father is not around and history is unknown. Uncle is an occasional beer drinker. No reported history of substance abuse with and mother is the only family member with mental health diagnosis.

Psychosocial History: Client is born and rainsed in Los Angeles living with single mother (43) and younger (15) male sibling and Uncle (47) who is related to his mother. Patient is a recent high school graduate who is unsure if he will continue college but has plans on applying to local community college. Is currently in a supportive and non-stressful relationship with biological female but is not currently sexually active. Not currently working and is reliant on mother for financial support. No hobbies reported with patient endorsing that he mostly hangs out with partner and doesn’t like to be in large crowds due to social anxiety. No military experience, no legal matter and no firearms reported in the house.

Medical History: Denies

Current Medications:

Prozac 20 MG TAB, PO. Take one (1) tablet daily.

Buspirone 5 MG TAB, PO. Take two (2) tablets in the AM and take one (1) tablet in the evening.

Hydroxyzine 10 MG tAB, PO. Take one (1) tablet at night as needed for sleep.

Allergies: NKA

Reproductive Hx: No kids, not sexually active, No STD’s, LMP: Early June/2024,

ROS:

GENERAL: No chills, fever or weight gain or loss.
HEENT: HEAD normocephalic, EYES: without blurry/double vision, EARS: No hearing loss or ringing in the ears, NOSE: Without runny nose or nasal congestion, THROAT: No swelling or sore throat.
SKIN: Without wounds, rashes or bruising.
CARDIOVASCULAR: No chest pain, palpitations or edema.
RESPIRATORY: No acute distress, sputum or SOB.
GASTROINTESTINAL: Normal bowel movements without constipation or difficulty.
GENITOURINARY: No burning, difficulties, urgency upon urination
NEUROLOGICAL: No tingling or numbness, no syncope or dizziness.
MUSCULOSKELETAL: Upper and lower extremities equal in strength and movement.
HEMATOLOGIC: No bleeding, anemia, or bruising.
LYMPHATICS: No splenectomy and no swollen lymph nodes.
ENDOCRINOLOGIC: No heat/cold intolerance. No chills or heat flashes.

Objective:

Diagnostic results:

PHQ-9 (depression): Score 19 Moderate Severe

GAD-7 (anxiety): Score 20 Severe

Height: 5’8” Weight” 140 lbs BMI: 21.3

Assessment:

Mental Status Examination:

Patient is a 17 year old transgender male who appears stated age well nourished with average height and weight. Client is adequately groomed and properly dressed with fair eye contact. Mood is depressed and anxious presenting with linear and goal-oriented thoughts process. Denies hallucinatons, paranoia, and no pre-occupation. Patient presents with fair insight/judgment into mental health needs and challenges. Patient is currently denying thoughts for harm to self or others and is without safety concerns.

Diagnostic Impression:

Major Depressive Disorder, recurrent, severe without psychotic features (F33.2). DSM‐5 remained close to DSM‐IV; the criteria are still nine and a diagnosis require at least five of these to be present, of which one must be low mood or loss of interest (Lundin, Moller & Forsell, 2021). For this patient, he has been experiencing increased depression, low energy, inability to enjoy activities, poor concentration and self-harm behavior.

Generalized Anxiety Disorder (GAD) (F41.1) While being anxious can be a normal response to stressful situations, when this emotion is triggered excessively, becomes difficult to control or is felt without a specific cause, it may be symptomatic of an anxiety disorder (Parsons et al., 2022).

Post Traumatic Stress disorder (PTSD) (F43.1) Consistently high rates of exposure to trauma, as well as conceptualizations of health disparities positing that chronic marginalization increases vulnerability to physical and mental health conditions would suggest higher prevalence of posttraumatic stress disorder (PTSD) in TGD populations relative to cisgender populations (Valentine et al., 2023). Because of the trauma the patient has had to deal with, PTSD could be a diagnosis, but the above diagnosis fit the patient a little better.

Reflections:

Living in Los Angeles, we encounter a wide spectrum of patients that will have their own unique challenges that require specific attention, needs and care when developing a comprehensive treatment plan. Patients who are transgender face challenges of not being accepted or respected which can contribute to negative mental health challenges. Patient has had dificuly with social interaction which might be contributing to increased depression over the last four months. Patient is currently in therapy and as a psychiatric provider we rely on a host of individuals to help stabilize our patient population. A concern I have, is if the current therapy is providing a safe place for client to express thoughts and feelings which will allow for the client to find success in therapy as part of his comprehensive care. Therapists are generally ill-equipped to work with transgender, nonbinary, and gender-nonconforming (TNG) clients owing to insufficient training, stigmatizing beliefs, and a tendency to misattribute presenting concerns to TGN identity (Budge, Sinnard & Holt, 2021). Patients care and needs will be closely monitored with treatment plan adjustments as the patient will have addition/adjustment is medications and treatment planning.

Case Formulation and Treatment Plan:

Plan Development: Client with history of depression and anxiety which has had a negative impact on the patients over-all wellbeing. Patient has had struggles with school towards the end of the school year which could have more impact on clients mental health challenges. A comprehensive plan is essential if the patient will have the ability to find mental health stabilization. The patient is with support and housing from mom which is helpful for the client, but the challenges of being transgender will present as a challenge as the care, needs and services might be inadequate and challenged by biases from indivudals within the mental health community. Negative attitudes and discrimination toward the transgender community create inequalities that prevent the delivery of competent healthcare and elevate the risk for various health problems (Robinson & Roper, 2021). There is a need to have an ongoing plan development to ensure that the client is receiving adequate throughout the treatment planning and development.

Plan: Continue medication as prescribed with Hydroxyzine being added for anxiety and insomnia. Education provided for emergency resources including 911, suicide hotline and local emergency rooms. Many students with severe mental health problems do not seek treatment due to obstacles including stigma, perceived ineffectiveness of treatment, financial barriers, and lack of time (Hong et al., 2022). Obtain labs work: (CBC, CMP, Lipid panel, A1c, TSH, Urinalysis, UTOX, pregnancy test). Inquire about therapy and its affectiveness with the client and his struggles manging and coping with depression and anxiety. Follow up appointments to address any new or worsening symptoms and to adjust medication as needed. Patient and mother want to give medication more time to reach therapeutic levels before adjustment in medication dosage after education provided with time of depressive medication can be fullt effective.

Goals: Provide psychotropic medications to help manage and decrease psychotic symptoms preventing the need for emergency hospitalizations and to prevent destructive behaviors of self-harm and the thought of wanting to harm self. Goals and plan discussed with patient and mother with both giving consent with signed documentation.

Questions

How does your individual beleifs (personal/religious) play a role in your treamnt and communication with a patient who is transgender?

Does your respective state allow/require parent consent when treating transgender adolescents?

In California, rights are bring established that will take away the rights from the parents and giving them to the adolescent when it comes to gender-affirming care. An adolescent can get their care and treatment without the parents/caregivers ever knowing and has become a sanctuary for out of state patients looking for care and treatment due to Senate Bill 107. This bill would prohibit a provider of health care, a health care service plan, or a contractor from releasing medical information related to a person or entity allowing a child to receive gender-affirming health care or gender-affirming mental health care in response to a criminal or civil action, including a foreign subpoena, based on another state’s law that authorizes a person to bring a civil or criminal action against a person or entity that allows a child to receive gender-affirming health care or gender-affirming mental health care (legislature.ca.gov, 2021).

Is identifying as transgender considered a mental health illness?

Everyone has their own experiences, thought and beliefs when it comes to individuals who identify as transgender. The third question is to test your beliefs and how it could possibly affect your treatment of this patient.

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

Budge, S. L., Sinnard, M. T., & Hoyt, W. T. (2021). Longitudinal effects of psychotherapy with transgender and nonbinary clients: A randomized controlled pilot trial. Psychotherapy, 58(1), 1–11. https://doi.org/10.1037/pst0000310

Goldblatt, M. J., Sher, E., Ronningstam, E., & Lindner, R. (2024). Psychotherapy for suicidal transgender and nonbinary people. Practice Innovations. https://doi.org/10.1037/pri0000233

Hong, V., Busby, D. R., O’Chel, S., & King, C. A. (2022). University students presenting for psychiatric emergency services: Socio-demographic and clinical factors related to service utilization and suicide risk. Journal of American College Health : J of ACH, 70(3), 773–782. https://doi.org/10.1080/07448481.2020.1764004

Bill text (no date) Bill Text - SB-107 Gender-affirming health care. Available at: https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202120220SB107 (Accessed: 18 June 2024).

Lundin, A., Möller, J., & Forsell, Y. (2023). The Major Depression Inventory for diagnosing according to DSM-5 and ICD-11: Psychometric properties and validity in a Swedish general population. International Journal of Methods in Psychiatric Research, 32(4), e1966. https://doi.org/10.1002/mpr.1966

Parsons, E., Ackerley, B., Thomson, H., Lawton, G., & Robson, D. (2024). ANXIETY. (cover story). New Scientist, 262(3485), 30–39.

Robinson, F. P., & Roper, S. L. (2021). Providing Competent, Supportive Care for People Who are Transgender. Colorado Nurse, 121(4), 22–23.

Valentine, S. E., Smith, A. M., Miller, K., Hadden, L., & Shipherd, J. C. (2023). Considerations and complexities of accurate PTSD assessment among transgender and gender diverse adults. Psychological Assessment, 35(5), 383–395. https://doi.org/10.1037/pas0001215