Based on the attached case study, please answer the following questions with references to support. Questions 1. What strategies can be implemented and monitored to ensure the patient's

Complex Case Presentation Janet Oludoyi Bogunjoko College of Nursing -PMHNP, Walden University PRAC 6675: PMHNP Care Across the Lifespan I Dr. Janaya Evenson July, 10th 2024 NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 2 of 11 Complex Case Presentation This case involves a 14 -year -old white male, an 8th grader, who presents with significant symptoms of anxiety, depression, and insomnia. Diagnosed with autism at the age of 2, though high functioning, he has been faced with ongoing challenges with social interactions and emotional regulation. Despite developmental delays and difficulties maintaining friendships, he has strong support at school and is involved in wrestling. He has a family history of depression and anxiety, pa rticularly in his mother line. The goal is to manage his symptoms through medication, psychotherapy, and lifestyle modifications while ensuring his safety and emotional well -being. Labs such as urinalysis , CBC, CM P, Thyroid function, T3 and T4 with Lipid Panel were not ordered because mom came with results with were less than a month from his primary doctor and all results were within normal limits. Questions 1. What strategies can be implemented and monitored to ensure the patient's safety and address any potential risk of self -harm? 2. How can coping strategies be developed and reinforced to help the patient manage anxiety symptoms and improve emotional regulation? NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 3 of 11 Subjective: Initials D.B Age: 14 Sex: M Race: Caucasian CC (chief complaint): “Dealing with people and emotions has always been a struggle”. It makes it hard to deal with social events.” HPI : The patient is a 14 -year -old white male 8th grader who reports “dealing with people and emotions has always been a struggle.” He finds it hard to deal with social events. He has inconsistent sleeping patterns due to some sleep disturbances, despite takin g melatonin 5 mg. He has difficulty falling and staying asleep, sleeping about 2 to 3 hours at night with wakeful moments. The patient struggles with anxiety and depression, exhibiting symptoms such as restlessness, edginess, irritability, worry, impulsivity, anxiety, nervousness, and difficulty concentrating. He denies any suicidal ideation (SI), homicidal ideation (HI), auditory or visual hallucinations (AVH), or urges to engage in self -injurious behavior. He denies any manic or hypomanic states and has no delusions, obsessions, or psychosis. T he patient scored 18 on the GAD -7 and PHQ -7. He admitted to having suicidal ideation but with no intention or plan to carry it out and gave a verbal contract for safety. Family Psychiatric/Substance Use History : The patient's mother has a history of depression and anxiety. Psychosocial History: The patient lives with his mother and father. He has friends at school and participates in wrestling. He does not relate to any spiritual or cultural factors. Born at 30 weeks with developmental delays, he struggles to maintain friendships and finds school challenging, though he has excellent support. He denies any legal history. NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 4 of 11 Substance Current Use: Denies any history of substance use. Medical History: ● Current Medications : Doxycycline 100 mg twice a day for Lyme disease Vistaril 25 mg as needed for anxiety and Insomnia Zoloft 50mg daily for depression ● Allergies : Seasonal allergies ● Reproductive Hx : Not applicable ROS : ● GENERAL: Reports restlessness, irritability, and fatigue. ● HEENT: No complaints of headaches, visual changes, or hearing issues. ● SKIN: ● CARDIOVASCULAR: No chest pain, palpitations, or edema. ● RESPIRATORY: No shortness of breath, cough, or wheezing ● GASTROINTESTINAL: No abdominal pain, nausea, vomiting, or changes in bowel habits. ● GENITOURINARY: No dysuria, frequency, or incontinence ● NEUROLOGICAL: No seizures or other neurological symptoms were reported. ● MUSCULOSKELETAL: No joint pain, stiffness, or muscle weakness. ● HEMATOLOGIC: No history of easy bruising or bleeding. ● LYMPHATICS: No swollen lymph nodes. NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 5 of 11 ● ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Objective: VS: Temp 9 7.6; BP 1 10 /72 ; RR 16; P 78 Diagnostic results : GAD -7 Score (18): The Generalized Anxiety Disorder 7 -item (GAD -7) scale is a reliable and validated tool for screening and assessing the severity of generalized anxiety disorder (Johnson et al., 2019). A score of 18 indicates a high level of anxiety. This is important for t he patient as it quantifies the severity of his anxiety symptoms, which include restlessness, edginess, worry, and difficulty concentrating. PHQ -7 Score (18): The Patient Health Questionnaire 9 -item (PHQ -9) scale, adapted here as PHQ -7, is a widely used tool for diagnosing and assessing the severity of depression. A score of 18 indicates moderate to severe depression. This score is significant for the patient as it captures the extent of his depressive symptoms, which include irritability, nervousness, and sleep disturbances. Assessment: Mental Status Examination: The patient appears well -groomed and dressed appropriately for his age. His behavior is cooperative, and he maintains eye contact. His speech is of normal rate and volume. His mood is anxious and depressed, with an affect congrue nt with his mood. His thought process is logical and goal -directed, with no delusions, obsessions, or psychosis noted. There are NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 6 of 11 no auditory or visual hallucinations affecting his perception. He is alert and oriented to person, place, and time. His insight and judgment are both good. Diagnostic Impression: 1. Generalized Anxiety Disorder GAD is characterized by excessive anxiety and worry occurring more days than not for at least six months, about several events or activities (DeMartini et al., 2019). The individual finds it difficult to control the worry and the anxiety is associated with three (or more) of the following six symptoms: restlessness, being easily fatigued, difficulty concentrating, irritabi lity, muscle tension, and sleep disturbance. The patient exhibits symptoms such as restlessness, edginess, irritability, worry, and diffi culty concentrating. The anxiety is pervasive and impacts various aspects of his life. Panic disorder is ruled out as the patient does not report experiencing panic attacks. Social anxiety disorder is excluded since the anxiety is not limited to social situatio ns but is generalized. Adjustment disorder is ruled out due to the chronic nature of the anxiety exceeding the six -month requirement and the pervasive impact across various domains. 2. Major Depressive Disorder (MDD), Recurrent Episode, Moderate: MDD is characterized by the presence of five (or more) of the following symptoms during the same two -week period, representing a change from previous functioning: depressed mood most of the day, diminished interest or pleasure, significant weight loss or g ain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate, and recurrent thoughts of death (Humer et al., 2023). These symptoms ca use clinically significant distress or impairment in social, occupational, or other important areas of functioning. The patient reports symptoms such as irritability, nervousness, sleep disturbances, and difficulty concentrating. The NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 7 of 11 patient’s mood is consistently anxious and depressed. Persistent depressive disorder is ruled out as the symptoms are not chronic over two years but rather present in episodic bouts. Bipolar II disorder is ruled out due to the absence of hypomanic episodes. Adjustment disorder with depressed mood is ruled out due to the severity and persistence of the symptoms which meet the criteria for MDD. 3. Insomnia disorder Insomnia disorder is characterized by dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms: difficulty initiating sleep, difficulty maintaining sleep, or early -morning awakening with an inability to return to sleep. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Riemann et al., 2022). The patient reports difficulty falling asleep and staying asleep, and inconsisten t sleep patterns, with frequent wakefulness and sleep lasting only 4 to 5 hours per night. Circadian rhythm sleep -wake disorder is ruled out as the patient’s sleep difficulties are not related to a misalignment between the sleep -wake schedule required by t heir environment and their circadian rhythm. Sleep apnea is ruled out due to the lack of reported symptoms such as loud snoring or observed apneas. MDD with insomnia is ruled out because, although the patient has depressive symptoms, insomnia is a prominen t and standalone issue, warranting a separate diagnosis of insomnia disorder. Reflections: This case of a 14 -year -old male with autism, anxiety, depression, and insomnia has provided valuable insights into the complexities of managing multiple psychiatric conditions in a young adolescent. One of the key lessons learned is the importance of a com prehensive and multidisciplinary approach to treatment, integrating pharmacotherapy, psychotherapy, and NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 8 of 11 lifestyle modifications to address the varied and interrelated symptoms. The need for continuous monitoring and adjustment of the treatment plan to ensure its effectiveness and appropriateness was also highlighted. Additionally, the case underscores the si gnificance of personalized care, considering the patient's developmental history, family dynamics, and support systems. Beyond the standard concerns of confidentiality and consent, this case raises important ethical issues related to the autonomy and involvement of a minor in their treatment. Ensuring the patient’s understanding and agreement with the treatment plan, while also respecting parental involvement, is crucial. Another consideration is the ethical responsibility to provide evidence - based care and to continually assess the benefits and potential risks of prescribed medications, particularly given the patient’s youn g age and developmental stage. Informed consent must be obtained from both the patient, as appropriate for his age, and his parents, ensuring they understand the potential side effects and benefits of the treatment options. Given the patient's age and developmental challenges, health promotion efforts should focus on building resilience, developing healthy coping strategies, and fostering a supportive social environment. Education on sleep hygiene, stress management technique s, and the importance of physical activity can help mitigate some of the symptoms of anxiety and depression. Considering the patient's autism diagnosis, interventions should be tailored to his unique needs, emphasizing clear communication, structured routi nes, and consistency in care. The history of developmental delays and the current mental health conditions necessitate a collaborative approach involving educators, mental health professionals, and the family. Ensuring that the patient feels heard and invo lved in his care plan is crucial for his engagement and adherence to treatment. NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 9 of 11 Case Formulation and Treatment Plan: The treatment plan involves continuing with current medications: Doxycycline 100 mg twice da ily for 7 more days, Vistaril 25 mg daily as needed , and Zoloft 50 mg daily. Weekly psychotherapy sessions are scheduled, with the initial appointment set for next Wednesday at 11 am. Monitoring of medication effectiveness and appropriateness will be ongoing. Psychotherapy sessions will primarily focus on safety planning, enhancing coping strategies for managing anxiety symptoms, and exploring relaxation techniques. Emphasis will be placed on utilizing effective coping skills to regulate mood and emotions. The therapy will also involve identifying triggers, antecedents, and consequences associated with anxiety episodes. Encouragement will be given to maintaining a healthy lifestyle through regular exercise and a balanced diet. Proper sleep hygiene practices will be reinforced to support better sleep quality. Ensuring adherence to prescribed medications and their therapeutic regimen will be a key part of the treatment plan. A follow -up appointment is scheduled at the clinic in 14 days to review progress and make any necessary adjustments to the treatment plan. NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 10 of 11 PRECEPTOR VERIFICATION : 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: ________________________ NRNP/PRAC 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template © 2022 Walden University Page 11 of 11 References DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine , 170 (7), ITC49 -ITC64. https://doi.org/10.7326/AITC201904020 Humer, E., Kocsis -Bogar, K., Berger, T., Schröder, J., Späth, C., Meyer, B., ... & Klein, J. P. (2020). A comparison of the three year course between chronic depression and depression with multiple vs. few prior episodes. Psychiatry research , 291 , 113235. https://doi.org/10.1016/j.psychres.2020.113235 Johnson, S. U., Ulvenes, P. G., Øktedalen, T., & Hoffart, A. (2019). Psychometric properties of the general anxiety disorder 7 -item (GAD -7) scale in a heterogeneous psychiatric sample. Frontiers in psychology , 10 , 1713. https://doi.org/10.3389/fpsyg.2019.01713 Riemann, D., Benz, F., Dressle, R. J., Espie, C. A., Johann, A. F., Blanken, T. F., ... & Van Someren, E. J. (2022). Insomnia disorder: State of the science and challenges for the future. Journal of sleep research , 31 (4), e13604. https://doi.org/10.1111/jsr.13604