Comprehensive Psychiatric Soap Note for Nursing Students

Comprehensive Psychiatric Soap Note for Nursing Students

Subjective:

Chief complaint: Petunia reports, “I have a history of taking medications and then stopping them. I do not think I need them. I really feel like the medication squashes who I am”.

History of present illness (HPI): Petunia Park is a 26-year-old African American female who presents for mental health assessment. Petunia complains of a history of taking and stopping the medication. She has tried Zoloft, Risperidone, Seroquel, and Klonopin and stopped, with the latter having a positive influence. Petunia claims that Zoloft made her high, causing her sleeplessness. Risperidone caused her racing mind and gain weight. Seroquel also made her gain weight. Generally, she claims that the medications are ineffective and affect her personality and creativity. Petunia reports that she has been hospitalized four times with depression, anxiety and bipolar conditions. One of her hospitalizations was from Benadryl overdose due to suicide gestures. She has had a history of lack of sleep, during which she was hospitalized and reported hearing things. Growing up, her dad was hard and yelled at her. Petunia reports having depressive episodes about four or five times a year. When this happens, she does not feel like getting out of bed, no energy or motivation. Petunia also reports losing interest in her creativity after working for five days. During the creative episodes, Petunia argues that she has experienced lots of energy and squashed, does not sleep for five days. During the creativity episodes, Petunia does not eat or sleep accordingly. She hears voices when she experiences irregular sleeping patterns.(Comprehensive Psychiatric Soap Note for Nursing Students)

Past psychiatric history: Hospitalized four times, the last being the past spring and first admitted as a teenager following five days of lack of sleep and “hearing somethings.” She was admitted in 2017 due to a Benadryl overdose. Diagnosed with depression, anxiety, and bipolar.(Comprehensive Psychiatric Soap Note for Nursing Students)

Medication trials and current medications: Tried Zoloft, Risperidone, Seroquel, and Klonopin, among others. Uses hypothyroidism drugs and birth control pills for polycystic ovaries.(Comprehensive Psychiatric Soap Note for Nursing Students)

Psychotherapy or previous psychiatric diagnosis:

Pertinent substance use: Uses nicotine, smokes a pack daily. Denies abuse of alcohol, cocaine, and marijuana. Denies use of any stimulants or methamphetamines. Denies huffing, inhalants, or any sedative medications. Denies hallucinogenic substances, including LSD, PCP, or mushrooms.(Comprehensive Psychiatric Soap Note for Nursing Students)

Family psychiatric/substance use: Mother diagnosed with bipolar. Father had a history of drug abuse. Brother is perceived to be schizophrenic.

Social history: Raised by the mother together with his brother and not married. Has no children. Practices and explore multiple sexual activities. Denies any legal issues or DIUs. Part-time work at a bookstore. She is in a vocational training school studying cosmetology.(Comprehensive Psychiatric Soap Note for Nursing Students)

Medical history: Denies pills, opiates, or any other prescribed or non-prescribed medications. Denies use of spice, or ecstasy, bath salts, mollies, or any other synthetics.

Reproductive Hx: Normal menstruation, last month. Not pregnant. Uses birth control pills. Has multiple sexual partners.  (Comprehensive Psychiatric Soap Note for Nursing Students)

Allergies: None reported.

ROS:

GENERAL: Well-nourished and presentable. Not distressed. The client appears slightly irritated with specific questions.

HEENT: No visible head scaring or depressions, normal vision and hearing. No external mucosa or teeth issues.

SKIN: No rash, hives, lesions or bruising.

CARDIOVASCULAR: No chest pain or palpitations.

RESPIRATORY: No respiratory infection.

GASTROINTESTINAL: Reports loss of appetite and excessive eating episodically.   

GENITOURINARY: Not pregnant. Regular menses.

NEUROLOGICAL: Reports hearing voices. No headaches.  

MUSCULOSKELETAL: No back pain. Does not exercise.

HEMATOLOGIC: No unusual bleeding, possible exhaustion.

LYMPHATICS: No lymph node tenderness or enlargement.

ENDOCRINOLOGIC: Reports hypothyroidism.

Objective:

Diagnostic results: A thyroid function test is necessary to ascertain the client’s hypothyroidism. Mental health-related symptoms such as emotional lability, fatigue, and depression are associated with hyperthyroidism (Bathla, Singh, & Relan, 2016). A psychiatrist assessment and physical examination are crucial for evaluating the client’s mental health and differentiating the associated symptoms from hypothyroidism. Although a thyroid test reveals hypothyroidism, the patient’s conditions are attributed to mood disorder. However, hypothyroidism could be affecting her response to medication.(Comprehensive Psychiatric Soap Note for Nursing Students)

Assessments

Mental Status Examination: Petunia is oriented ×3. Her thought content, speech and behaviour are normal. She is well dressed and conversant with the occasion. She responded to the doctor’s question appropriately and exuded a wealth of vocabulary. Her memory and judgment appeared intact as she recalled most of her medical, social, and family history. Petunia is composed, has no suicide or homicide ideation, and does not appear to risk herself and others.(Comprehensive Psychiatric Soap Note for Nursing Students)

Diagnostic Impression: Park’s symptoms are consistent with recurrent depressive disorders. For instance, Park experiences periodic insomnia, hyper insomnia, fatigue, poor appetite, overeating, and low self-esteem (American Psychiatric Association, 2020). The client experiences a change in mood from previous functioning and at least five days of low energy after working for weeks. The client’s symptoms are also consistent with recurrent major depressive disorder. The client experienced a depressive mood most of the day during depressive episodes and diminished interest in her creativity after working for five days. She also experiences fatigue after prolonged activity. Lastly, Petunia’s symptoms are consistent with a bipolar disorder characterized by elevated moods lasting weeks. According to Marzani & Neff (2021), maniac disorders are characterized by high and irritable moods that last a week. Petunia reports creativity episodes during which she does not sleep for five days, has multiple sexual experiences, and inflates self-esteem.(Comprehensive Psychiatric Soap Note for Nursing Students)

Reflections: I agree with the preceptor’s approach and the content of her examination. It is vital to inform the client about her prognosis and necessary intervention. There is a need to agree with the client on the therapy modality. Moreover, I would discuss with the client on confidentiality of her mental health condition and the need for involvement in social activity for mental health management. According to Tough, Siegrist, & Fekete (2017), socialization Socialization is associated with a lighter mood, happiness, sense of safety, security and belonging. Allows you to confide in others and let them confide in you. I will discuss the importance of maintaining a healthy diet and its role in her general health and medication adherence with the client. The client appears stable and is not a threat to himself and others. For this reason, she needs outpatient medication, as this would also enable her to interact with others.(Comprehensive Psychiatric Soap Note for Nursing Students)

Case Formulation and Treatment Plan:

Medication: I would prescribe Escitalopram 10g per day. Escitalopram is effective and well-tolerated for major depressive disorder, anxiety, and bipolar disorder. This is because the client had negative experiences with the other common medication.(Comprehensive Psychiatric Soap Note for Nursing Students)

Exercise: I would recommend the client to exercise for 45-minutes daily. Regular exercise is vital in easing depression and anxiety symptoms, negative moods, self-esteem, and cognitive function. Physical exercise releases endorphins, i.e., feel-good hormones and other chemicals that enhance wellbeing (Schmitter et al., 2020). Physical exercise augments Pharmacotherapeutics intervention.(Comprehensive Psychiatric Soap Note for Nursing Students)

Socialization: Recommend community peer groups and social activities to get involved in. Socialization is associated with a lighter mood, happiness, sense of safety, security and belonging (Tough et al., 2017).

Referral: Refer the client to a psychiatrist for further mental health assessment and recommendation.

References

American Psychiatric Association. (2020). The American psychiatric association practice guideline for the treatment of patients with Schizophrenia. American Psychiatric Pub.(Comprehensive Psychiatric Soap Note for Nursing Students)

Bathla, M., Singh, M., & Relan, P. (2016). Prevalence of anxiety and depressive symptoms among patients with hypothyroidism. Indian journal of endocrinology and metabolism, 20(4), 468. (Comprehensive Psychiatric Soap Note for Nursing Students)https://dx.doi.org/10.4103%2F2230-8210.183476

Marzani, G., & Neff, A. P. (2021). Bipolar Disorders: Evaluation and Treatment. American Family Physician, 103(4), 227-239(Comprehensive Psychiatric Soap Note for Nursing Students). https://pubmed.ncbi.nlm.nih.gov/33587568/

Tough, H., Siegrist, J., & Fekete, C. (2017). Social relationships, mental health and wellbeing in physical disability: a systematic review. BMC public health, 17(1), 1-18(Comprehensive Psychiatric Soap Note for Nursing Students). https://doi.org/10.1186/s12889-017-4448-8