Comprehensive Focused SOAP Psychiatric

NRNP/PRAC Comprehensive Focused SOAP Psychiatric Evaluation Template

Instructions/Descriptions

NRNP/PRAC Comprehensive Focused SOAP Psychiatric Evaluation Template

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Week (enter week #): (Enter assignment title)

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): “I have been feeling helpless since my wife past wy two months ago, and I want to commit suicide because im too lonely.”

HPI: William is a 62-year-old male who presents to the facility with complaints of feeling hopeless and suicidal ideations due to loneliness. These symptoms began two months ago after his wife passed away following a tragic road accident. He states that his wife was his only companion, and now he is hopeless and helpless. He claims that he wants to join her in the other world to continue being together.

Substance Current Use: He only smokes five cigars a day. He used to take a bottle of beer twice a week, but since the death of his wife, he has been drinking around three bottles daily to get sleep.

Medical History:

• Current Medications: metformin 500mg BD for type 2 diabetes. (He states that he has been missing some doses)
• Allergies: He has no known allergies
• Reproductive Hx: heterosexual. He is sexually inactive.

ROS:

• GENERAL: he states to have lost weight. No fever or chills were reported.
• HEENT: Head: he denies head trauma or headache; Eyes: he uses reading glasses. Otherwise, his eyes are healthy. No pain or abnormal tearing was reported; Ears: he states that his hearing has reduced. no ringing was reported.; Nose: he denies nose bleeding or postnasal drainage.; Throat: no swallowing difficulties said. There is evidence of missing teeth on the upper jaw.
• SKIN: The skin is wrinkled. There is an erythematous bruising around the neck. The patient says it was a suicide attempt.
• CARDIOVASCULAR: no palpitations and chest discomfort. The heart rate is within normal range, and the rhythm is regular. he reports shortness of breath on exertion only
• RESPIRATORY: respirations are slow, steady, and unlabored. he denies difficulty in breathing
• GASTROINTESTINAL: he reports reduced appetite. bowel sounds are diminished, and the last bowel movements were two days ago
• GENITOURINARY: no concerns reported. prostate exam conducted two weeks ago
• NEUROLOGICAL: he reports reduced sleep but denies headaches, blackout spells, or seizures.
• MUSCULOSKELETAL: reports mild stiffness of joints that began last week. The joints are painless.
• HEMATOLOGIC: he denies uncontrolled bleeding or coagulopathies.
• LYMPHATICS: cervical lymph nodes are swollen and tender.
• ENDOCRINOLOGIC: no extreme hunger or thirst was reported.

Objective:

Diagnostic results: no tests were ordered.

Assessment:

Mental Status Examination:

The patient is a 62 years old male whose appearance corresponds to his stated age. He is alert and oriented to place. Time and person. He is roughly groomed, with uncombed grey hair. He is appropriately dressed for the weather. He speaks in a clear voice with a low tone. His thought process is interfered, logical, and goal-oriented. He does not show any sign of flights of ideas or loose association. His mood is sad, with an effect that corresponds to his mood. He does have alerts of delusional thinking, and he does not report any visual or auditory hallucinations. He reports multiple suicidal ideations and failed suicidal attempts. He reports planning to kill his dog and cat before committing suicide. He has good concentration, and both long-term and short-term memories are intact, with poor insight.

Diagnostic Impression:

Major depressive disorder (MDD): Depression, often referred to as major depressive disorder or clinical depression, is a significant mood condition that affects many people. Depression causes people to feel unhappy and hopeless all of the time, and they lack enthusiasm for things they used to like (WHO, 2020). Apart from the psychological concerns that depression causes, people may also have physical disturbances like persistent pain or gastrointestinal issues. Patients may present with either too much or very low appetite and altered sleeping patterns. In extreme cases, patients can present with suicidal ideations, self-inflicted harm, and homicidal ideations. The patients described in this case study present with all the above complaints. Hence it is considered the primary diagnosis.

Anxiety: Anxiety is a mental problem characterized by a constant and overpowering worry. Anxiety and terror are symptoms. Panic, dread, and discomfort are common symptoms, as are feelings of impending doom or danger (Chand & Marwaha, 2022). They often come with sleep issues and difficulty remaining calm. Although the patient is afraid of living alone, he does not have a great magnitude of fear. most of the patient’s presentations are not characteristics of anxiety, and hence the diagnosis is ruled out

Adjustment disorder: When a person has a traumatic incident or significant shift in their life, they may have an adjustment disorder as a psychological or behavioral response. It is regarded as an abnormal or overwhelming response to an incident or change when it occurs within three months of the incident or transition taking place. Symptoms include, for example, Not liking things you used to appreciate because you’re sad, hopeless, or otherwise unhappy (O’Donnel et al., 2016). Crying on a regular basis. They may also be in attendance. Feeling worried or apprehensive, as well as tense, jittery, or agitated. Although the patient presents with most of these symptoms, it’s ruled out due to the patient’s presentation with suicidal ideations, which is uncommon in a patient with adjustment disorder.

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Reflections:

I think this is an emotional case to handle. Past psychiatric history for the patient was not obtained. If we were given a chance to reevaluate the patient, I would inquire about his psychiatric history to know whether he has experienced such symptoms before. This is because some mental disorders may relapse following a long period of recovery when triggered. It is crucial to know whether the patient has ever been treated for depression. This will also help to determine what drugs can be effective in treating the patient.

Case Formulation and Treatment Plan:

• The patient will be initiated on fluoxetine, which will help him to manage the depressive symptoms (Micheli et al., 2018)
• The patient will be referred to a psychiatrist for cognitive behavioral therapy or group therapy (Weck et al., 2015)
• He will be issued an emergency number to call in case of a suicidal emergency.
• He should return for evaluation after two weeks.

NRNP/PRAC Comprehensive Focused SOAP Psychiatric Evaluation Template

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