Week 4: Focused SOAP Note and Patient Case Presentation
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan 1
Introduction
An individual’s psychiatric examination should be complete and integrated.
crucial in the development of a correct psychiatric diagnosis Facts must be gathered from
numerous sources without bias in order to receive reliable knowledge. The goal of this
assignment is to gain an understanding of important questions to ask during an assessment and
how to effectively assess and diagnose a mood disorder based on information acquired from the
patient and objective information obtained during an interview by the PMHNP. After
interviewing the patient, the assessment was noted, and three differential diagnoses were
developed based on the information gathered during the interview session. A PMHNP was
referred to a 26-year-old White female patient for treatment and continued management of her
mental health problem. CC: “I have a history of taking medications and stopping them; I think the medication squashes who I am”.
HPI: J.P a 26-year-old White female who came in for medication management. Patient
is currently taking Zoloft which she complains made her high when she is creative and while
sleeping her mind will be racing. She also takes Risperidone which made her gain weight. Takes
Seroquel which made her gain weight as well, Klonopin, she complained it slowed her down.
Because of the above listed discomfort and side effects patient listed, patient stopped taking the
medication.
Substance History or Current use: Nicotine: smoke about a pack cigarette a day and will
not quit. Alcohol: admits to drinking alcohol but that was 19 years ago. Used marijuana some
years ago and got paranoid, stopped smoking it. Cocaine and other stimulants: denies use.
Caffeine: denies. Sedatives: Denies. Denies use of mushrooms. Denies use of pain pills or street
drugs. Denies use of any type of ecstasy drugs.
Family Psychiatric: Mother had bipolar, Father was arrested and had jail time in prison due to
drugs for 10 years now. Brother has schizophrenia but never went to hospital for treatment. No
family history of suicide. Patient admits that she tried to kill herself once in the past but I won’t
do it again.
Psycho-social History: Lives: lives with her mother and sometimes her boyfriend. Goes over to
her mother if her boyfriend’s gets mad at her for sleeping around. Work: employed; works with
aunt’s bookstore. Misses work when she is feeling low. Education: in school for cosmetology to
do make up for movie stars. Fun activities: writing her life story, paints Picasso. Arrest: police
picked patient up and took her the hospital that she was found dancing naked. Trauma: Father
was pretty tough and yelled at them a lot. Raised by mother and older brother.
Hospitalization: Patient have been admitted four times. Admitted for suicide
ideation: overdosed with Benadryl in 2017. When patient was a teenager, went for some days
without sleeping. They gave patient some medication in the hospital that she can’t remember the
name.
Psychiatric History: Depression, Anxiety, Bipolar. Depression: get depressed for about 4 to 5
times a year; when patient does not have any energy or creativity then patient feels depressed and
not want to do anything. During those episodes, are times when patient does not take her
medication. Patient denies being having anxiety at this time. Denies repetitive episodes or OCD.
Denies AVH/Delusions. Only hallucinates when she is not sleeping well; she hears voice. But
none at this time. Appetite: when creative she is too busy to eat, when she is crashing, she eats a