PMNHP SOAP Note-comprehensive nursing paper example

PMNHP SOAP Note-comprehensive nursing paper example

S.

CC- “self-esteem drops, and I feel rejection-sensitive and guilt-ridden for no apparent reason.”

HPI- Mr. X, a 26 YOCG, currently euthymic but has a history of major depressive episodes. Just before the manic episodes a few months ago, he was put on a selective serotonin reuptake inhibitor (SSRI) for SAD symptoms as well as depression. Within days of initiation of SSRI medication, he experienced elevated mood. (PMNHP SOAP Note-comprehensive nursing paper example)

PMNHP SOAP Note-comprehensive nursing paper example
PMNHP SOAP Note-comprehensive nursing paper example

            Mr. X says he seeks consultation because he has legal issues regarding drinking and driving that he thinks were likely fueled by his psychiatric symptoms. Some of the depressive episodes have been incapacitated and interfered with both school and work. In addition to having episodes of low self-esteem, rejection sensitivity, and guilt-ridden for no reason, he reports social anxiety symptoms and is often nervous around new people and acquaintances. Due to anticipatory anxiety experiences, he opts to avoid certain social events as the symptoms manifest independently of his affective state. The SSRI medication made him lose anxiety, fear, and avoidance. He was unusually talkative; had racing thoughts; was distractible, hyperactive, and impulsive; and had decreased need for sleep. He also exhibited grandiosity, in which he felt invincible and that the law did not apply to him. The mood elevation is complicated because Mr. X admits to heavy alcohol use on weekends throughout college. He reports that the mood elevation abated after SSRI cessation.(PMNHP SOAP Note-comprehensive nursing paper example)

Past Psychiatric HistoryThe patient though currently euthymic, has a history of major depressive episodes, most of which were untreated since his adolescence. The symptoms have varied in severity and length, manifesting as insomnia, depressed mood, low interest in activities, poor energy, and sad thoughts.(PMNHP SOAP Note-comprehensive nursing paper example)

Past Family Psych History- Has no BD family history, but the mother has Generalized Anxiety disorder (GAD).

Past Medical History- He is not under any medication currently. He had been started on a selective serotonin reuptake inhibitor (SSRI) for the depression and SAD symptoms in the past which was stopped after experiencing mood elevation.(PMNHP SOAP Note-comprehensive nursing paper example)

Social History- Upon graduation, the 26-year-old reports having a few friends and a very supportive family. He wants to be a news reporter.(PMNHP SOAP Note-comprehensive nursing paper example)

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O.

Labs, test results- A thyroid function test to measure the patient’s thyroid gland functions. This would help rule out hypothyroidism, another cause for depressive symptoms.(PMNHP SOAP Note-comprehensive nursing paper example)

Conduct a mental health evaluation and mood charting.

Vitals-98.8, 160/80, 76, 18, 5’10”, and 190 lbs

Review of Systems (ROS) – Patient reports mood swings from low self-esteem to guilt-ridden and fear of rejection for no apparent reason. He is also affirmative of insomnia, increased energy, and elevated moods when on SSRIs.(PMNHP SOAP Note-comprehensive nursing paper example)

The patient denies suicidal ideation, grandiosity exhibition, felt he was invincible and was above the law. These feelings made him pick a quarrel with a man in a bar, drive under the influence, and challenge authority when the police intervened.(PMNHP SOAP Note-comprehensive nursing paper example)

Mental Status Exam:

Orientation – oriented to person, place, and time

Appearance – appeared anxious and nervous

Behavior – nervous around new people and acquaintances

Attitude – cooperative

Rapport – candid and easy to establish

Speech and Language – clear, normal rate, rhythm, and volume

Mood – mildly depressed

Affect – congruent with mood

Thought Processes/Associations – logical and goal-directed

Thought Content – despondent thoughts

Suicidal/Homicidal Ideation – no suicidal or homicidal ideation

Cognitive – not formally tested but grossly within normal limits

Concentration – within normal limits

Abstraction – good

Serial Sevens – no errors

Memory – within normal limits

MMSE – 30/30

Insight – fair

Judgment – good

Psychiatric screening measure resultsThe psychiatric screening results report normal function of the thyroid gland.

A.

Findings- normal thyroid gland functioning established and mood charting indicative of episodes of mania and depressive episodes.

 DDx-

Intermittent explosive disorder unlikely because the patient does not report experiencing episodes of unwarranted anger.

Depression ruled out because of the absence of suicidal thoughts, attempts, or plans, although decreased energy, low self-esteem, and guilt-ridden are present.

Substance-Induced Psychotic Disorder or Substance Abuse: This does not seem likely. 8. Psychotic Disorder Due to a General Medical Condition: It seems that these symptoms have been present throughout most of life and have not developed along with any specific medical condition.

PMNHP SOAP Note-comprehensive nursing paper example
PMNHP SOAP Note-comprehensive nursing paper example 1

According to DSM-5  along with ICD-10 codes- The patient is in Bipolar II disorder since the BD does not interrupt the patient’s ability to function. Further Most likely diagnosis is BD due to the presence of mood swings. This diagnosis for bipolar disorder is made after ruling out other conditions where a thyroid function test is needed to rule out hypothyroidism. To diagnose bipolar disorder, the patient must have at least one depression episode and one manic or hypomanic episode after a mental health evaluation.(PMNHP SOAP Note-comprehensive nursing paper example)

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P.

Treatment Plan- Whether depressive, dysthymic, and mixed states constitute the majority of BD illness burden. The patient is prescribed antidepressants, mood stabilizers like carbamazepine for the short term, and lamotrigine and second-generation antipsychotics. The patient’s input is to engage in non-pharmacological interventions like psychotherapy. The treatment obstacles include the patient’s failure to adhere to the prescribed medication and his lack of knowledge on management and treatment options for BD.(PMNHP SOAP Note-comprehensive nursing paper example)

Continue Lamotrigine at 10 mg dose. If no further improvement is noted in the next 30 days, the provider will consider increasing the dose to 20mg. The medication will be reinforced with ongoing outpatient counseling. Follow-up is set in four weeks or earlier if any depressive episodes get worse.(PMNHP SOAP Note-comprehensive nursing paper example)

Copy any Case study questions from the instructions and answer here.

1.         Does the patient’s history support a diagnosis of bipolar disorder even though his symptoms appear to have been triggered by a selective serotonin reuptake inhibitor?

Yes, the patient’s history supports a bipolar diagnosis even before his manic symptoms became ‘full blown’ after he was put on SSRIs. Mental health experts admit that diagnosis bipolar disorder is not an easy task there aren’t lab tests to make a confirmatory diagnosis and its correct diagnosis has to rely on a combination of methods. Prior to being put on the SSRIs, the 26 year man was having depressive episodes impaired cognition, despondent thoughts, depressed mood and poor energy among others. For the bipolar disorder before diagnosis to have become manifest- the mania phase may have presented itself as recovery from the depression phase.(PMNHP SOAP Note-comprehensive nursing paper example)

2.         What would be the expected future course of illness for this patient?

Researchers in mental health have found evidence indicating that almost 50% of all Bipolar disorder diagnosed cases outgrow the condition between the ages of 18 and 25 years. However, since patient is already 26 years old one can expect the future course of the illness for the young man is the manic- depression phases will continue to cause severe and unusual mood shifts and energy that significantly impact on the patient’s to execute his daily tasks. Be that as it may, ongoing treatment and self-management can see the patient maintain stable moods for long periods of time.(PMNHP SOAP Note-comprehensive nursing paper example)

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3.         If the patient develops another depressive episode, how would you treat it?

To treat another depressive episode, I would use lamotrigine as it reduces the risk of depressive episodes recurrences on a long term basis.

4.         What medication would you choose (there could be many correct answers).

FDA has approved Lamotrigine for long term prophylaxis in BD. Other medications that could be used is lithium or even second generation antipsychotics like quetiapine, lurasidone, olanzapine – fluoxetine and cariprazine for short term treatment of BD acute depressive episodes. Taking Lamotrigine, despite its mechanism of action being not adequately understood, it belongs to the triazine group meaning that it selectively binds sodium channels. The binding then stabilizes the presynaptic neuronal membrane and therefore inhibits the release of glutamate. Lamotrigine is also believed to impact other neurotransmitters like dopamine, serotonin and norepinephrine. Another theory contends that Lamotrigine has the capacity to interact with voltage activated calcium gated channels triggering a wide range of activity.(PMNHP SOAP Note-comprehensive nursing paper example)

5.         Provide and reference a recent research article (Published over the last 3 years) on the  medication treatment of Mood Disorders

Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: a major unsolved challenge. International journal of bipolar disorders, 8(1), 1-13(PMNHP SOAP Note-comprehensive nursing paper example)

PMNHP SOAP Note-comprehensive nursing paper example
PMNHP SOAP Note-comprehensive nursing paper example 2

Reference

National Center for Biotechnology Information (nih.gov)

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