NRNP 6665 Comprehensive Focused Soap Note

NRNP 6665 Comprehensive Focused Soap Note

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): NM is a 16-year old male with a history of bronchitis, who reports to the outpatient room with, complains of productive cough for one week, shortness of breath that developed late last night, and fatigue for close to a week.

HPI: The symptoms have been worsening over the stay, with severe exhaustion on little exertion. The patient reports to have developed the cough 1 week ago, and visualized yellowish/green sputum, which comes with feverish feeling that she manages with chlorphenamine that she purchased over the counter. After experiencing severe shortness of breath last night while going upstairs, he decided to step into the hospital for check-up.

Substance Current Use: He denies any use of alcohol or smoking.

Medical History:

• Current Medications: He reports to be using chlorphenamine which he bought over the counter to mange fever.
• Allergies: He has no know food or drug allergies.

• Reproductive Hx: He denies being married or having any child. His reports to be sexually inactive at his age.

ROS:

• GENERAL: His general appearance portrays an athletic on heavy clothing not congruent with the weather.
• HEENT: He has no headaches or dizziness. Has no tinnitus or hearing loss. The nose is congested, with rhinitis, but has no epistaxis. His throat is dry and sore, with painful swallowing. No neck swellings.
• SKIN: The skin is free from rashes or jaundice
• CARDIOVASCULAR: No tachycardia or any cardiovascular disease.
• RESPIRATORY: Shortness of breath, sputum discharge, respirations above 32b/min, no chest pains.
• GASTROINTESTINAL: . Has no reports of nausea, vomiting, diarrhoea or reduced appetite.
• GENITOURINARY: Has no dysuria or hematuria.
• NEUROLOGICAL: GCS 15/15
• MUSCULOSKELETAL: He has optimal joint range of motion, no reports of muscle pain or numbness on extremities.
• HEMATOLOGIC: No signs of hypercoagulation or bleeding disorders.
• LYMPHATICS: Has no oedema on either limbs.
• ENDOCRINOLOGIC: No history of diabetes or hyperthyroidism.

Objective:

Diagnostic results:

His T-102.9, P-95, R-37, BP-118/84, PO2-93% off oxygen and BMI-19.4. His chest Xray indicates congested lungs.

Assessment:

Mental Status Examination: NM is a 16-year old athletic, appropriately dressed, clean and groomed. He has no signs of abnormal muscle movements. His speech is clear, audible and coherent. His thought process is logical, with no sign of disturbed thought content. He has an appropriate affect congruent to his mood. He denies any form of auditory, visual, tactile, olfactory or taste hallucinations. He also denies any sign of suicidal ideations, attempts or plans. He is alert and active, with optimal concentration.

Diagnostic Impression: With the report of rapid onset and high fevers, typical pneumonia is a probable diagnosis. His chest Xray indicating congested lungs also support the diagnosis. Coloured sputum also acknowledges a bacterial pneumonia (Sattar & Sharma, 2021). Right sided heart failure is contraindicated by absence of jugular distension or any oedema on the peripheries.

High fevers were an indication of present infection. Differential diagnoses include pulmonary embolism and congestive heart failure (CHF) (Htun et al, 2019). The former is supported by shortness of breath, although ruled out by the present progression of symptoms. The patient also lacks any risk to hypercoagulation or jugular distension. The latter is supported by cough, shortness of breath and family history of hypertension. However, the chest X-ray supports a normal ventilation perfusion process. Lack of oedema or jugular distension helps to rule out heart failure.

Reflections: I agree with the present diagnosis of pneumonia. Although symptoms are flu-like, the period of progression and severe shortness of breath indicate a possible severe infection in the lungs. The American Thoracic Society  recommends use of high dose amoxilin and clavulanic acid for patients with recent history of using amoxicillin. However, although eliminating a specific causative agent is difficult, an additional sputum culture could be advised, to guide the line of antibiotic therapy.

Case Formulation and Treatment Plan:

The medical plan of care will resume albuterol to open his airways hence resolve the shortness of breath. Amoxicillin with clavulanic acid oral dose is recommended as first line (Mantero et al, 2017). A non-steroidal anti-inflammatory drug such as ibuprofen also helps to reduce throat pain and possible inflammation. Oxygen supplementation may be indicated on need basis. The patient is also encouraged to increase fluid intake, and lots of vitamin foods (Nayar et al, 2019). The patient is also asked to report back in case of shortness of breath while at home.

NRNP 6665 Comprehensive Focused Soap Note References

• Htun, T. P., Sun, Y., Chua, H. L., & Pang, J. (2019). Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta-review. Scientific reports, 9(1), 7600. https://doi.org/10.1038/s41598-019-44145-y
• Mantero, M., Tarsia, P., Gramegna, A., Henchi, S., Vanoni, N., & Di Pasquale, M. (2017). Antibiotic therapy, supportive treatment and management of immunomodulation-inflammation response in community acquired pneumonia: review of recommendations. Multidisciplinary respiratory medicine, 12, 26. https://doi.org/10.1186/s40248-017-0106-3
• Nayar, S., Hasan, A., Waghray, P., Ramananthan, S., Ahdal, J., & Jain, R. (2019). Management of community-acquired bacterial pneumonia in adults: Limitations of current antibiotics and future therapies. Lung India : official organ of Indian Chest Society, 36(6), 525–533. https://doi.org/10.4103/lungindia.lungindia_38_19
• Sattar SBA, Sharma S, (2021). Bacterial Pneumonia. StatPearls Publishing; Available from: https://www.ncbi.nlm.nih.gov/books/NBK513321/

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Example

Subjective:

CC (chief complaint): W.P.N. is a 23-year-old African American male with a history of intrusive thoughts with images of vivid flashbacks and intense nightmares for 3 weeks. He also has bouts of nervousness, emotional tension and restlessness for the same duration, with a deep sense of impending doom and feeling increasingly tired and weak. He reports an obsession with recurring and persisting thoughts, images and urges for 3 weeks.

HPI: W.P.N. is a 23-year-old African American male with a history of intrusive thoughts with images of vivid flashbacks and intense nightmares for 3 weeks. He also experiences extreme physical sensations such as pain, trembling, nausea and sweating during the episodes of distress whenever he encounters a reminder of a traumatic event he underwent as a war veteran in Afghanistan several years ago. In instances, he has uncontrolled agitation with depressive spells where he engages in uncontrollable crying, alternating with thoughts of death and suicide (Lewis et al., 2020). 

However, he denies any suicidal attempts, claiming only to have suicidal ideation. He also states experiences of paranoia where he is completely distrustful of his environment and the persons around him (Lewis et al., 2020).  He has hypervigilance in that he is extremely cautious and ready to take action in case of imminent danger. W.P.N. reports trouble sleeping with terrifying nightmares that he describes as vivid.

In addition, W.P.N. experiences bouts of nervousness, emotional tension and restlessness for the last 3 weeks with panic, a deep sense of impending doom and feeling increasingly tired and weak. He reports difficulty concentrating on anything else apart from the current concerns. Furthermore, he experiences a raised heart rate with a pounding heart such that the heartbeat is audible, immense sweating, trembling and breathing very rapidly (DeMartini et al., 2019). There is also noteworthy difficulty sleeping, abdominal discomfort with bouts of diarrhea alternating with constipation and the urge to circumvent situations or items that may elicit anxiety.

W.P.N. also reports an obsession with recurring and persisting thoughts, images and urges for 3 weeks. He states that most of these thoughts are unwanted, intrusive and result in significant distress and anxiety (Goodman et al., 2021). Whenever he experiences these thoughts, he attempts to neutralize them with another action or thought, such as closing the curtains and windows in his house and locking all the doors. The obsessions and compulsions cause significant impairment of his functioning, particularly socially and occupationally, with severe distress clinically.

Substance Current Use: He occasionally smokes marijuana for recreation. He denies the use of other drugs such as heroin, cocaine, kuber or ecstasy. There is no substance use in his family.

Medical History:

•       Current Medications: He is currently not on any medication.
•       Allergies: He reports an allergic reaction to sulfur-containing medication, with the development of an erythematous rash all over his skin.

• Reproductive Hx: he is sexually active and engages in regular coitus with his wife, who is 3 years younger than him (Fasnacht et al., 2023)

ROS:

• GENERAL: he is well-kempt and well-nourished, and appears restless and agitated. He reports no generalized body swelling, weakness, or tenderness.
• HEENT: Review of the HEENT reveals normal hair distribution, with no visual loss, no tenderness, or palpable masses. His hearing and balance are intact (Fasnacht et al., 2023)
• SKIN: His skin has no rashes, no bruises or scars
• CARDIOVASCULAR: he has no neck distention but has awareness of heartbeat during the symptoms.
• RESPIRATORY: No chest pains, shortness of breath, or difficulty breathing.
• GASTROINTESTINAL: he has no abdominal pain, though he complains of occasional diarrhea alternating with constipation (Fasnacht et al., 2023)
• GENITOURINARY: No increase or decrease in urinary volume or frequency, no pain urinating or blood in urine
• NEUROLOGICAL: he has no blurred vision, no headache, no dizziness, no loss of consciousness.
• MUSCULOSKELETAL: musculoskeletal review reveals no muscle pains or stiffness, no joint pain, stiffness, or weakness (Fasnacht et al., 2023)
• HEMATOLOGIC: No fatigue, weakness, or dizziness, but palpitations present
• LYMPHATICS: No edema, tenderness, or lymphadenopathy
• ENDOCRINOLOGIC: tremors, sweating, no striae,

Objective:

Diagnostic results: During the psychiatric evaluation, the patient appears agitated, restless and confused. He avoids a healthy eye contact with the examiner and struggles to maintain a reliable rapport. Prior to the aforementioned symptoms, W.P.N. lived a satisfactory and happy life, where he worked as a senior security officer in one of the leading security agencies (Fasnacht et al., 2023). He was also sociable, pleasant and outgoing prior to the illness. He is a reliable member of the Baptist Church, where he serves as a bass guitarist. 

Also, he reports having a robust social support system, including his wife, two daughters, mother, father, two brothers, and three sisters. There is no known family history of mental illness. His thyroid function tests are normal for TSH, fT3 and fT4 (Fasnacht et al., 2023). His catecholamine levels are at the upper limit of the normal range, while his cortisol level is high normal. His echocardiogram is also normal, while the chest x-ray reveals a normal-sized heart.

Assessment:

Mental Status Examination: The patient appears generally aware of his environment at the commencement of the interview. This awareness shifts to bouts of confusion where W.P.N. ducks under the table as if evading bullets in a warzone. During the instances of reenacting the war, he is unresponsive to the examiner but is otherwise readily responsive when not in an episode. He is oriented in person but not in place as he believes he is still in Afghanistan or in time, as he states it is the night during the war while, in fact, it is morning (Fasnacht et al., 2023). His intelligence is intact as he is able to calculate the serial sevens from a hundred backward to zero without missing.

His semantic memory is impaired as he is unable to recall items in the order the interviewer prompts. His distance memory is intact as he recalls major events without straining. His judgment is intact as he states he will rescue a child from a house in flames using wet blankets for cover (Fasnacht et al., 2023). His thought process is faulty as he has intrusive, repetitive thoughts creating the desire to engage in action, though no racing thoughts, thought insertion, thought block or thought withdrawal. His mood is labile and agitated and his behavior appears confused and hypervigilant, as if waiting for something to happen (Fasnacht et al., 2023). The insight is fair as he notes that obsessive-compulsive thinking is absolutely not true.

Diagnostic Impression:

Post-traumatic stress disorder with differentials of acute stress disorder, dissociative disorders and depression. DSM-5 rules out acute stress disorder as the latter has no intrusion symptoms after the traumatic event (APA, 2013). Dissociative disorder requires a loss of identity in escaping from the reality of undesirable events. DSM-5 rules out dissociative disorder as W.P.N has his identity intact (APA, 2013). Whereas suicidal thoughts or attempts, hypervigilance, poor sleep, agitation and lack of concentration characterize both depression and post-traumatic stress disorder, the former has no intrusive distressing memories, according to DSM-5.

Generalized anxiety disorder with differentials of depressive disorder, psychotic disorder and personality disorder. While depressive patients have apathy and anhedonia, anxiety patients constantly worry about activities or events such as school or occupational performance (APA, 2013). However, according to DSM-5, psychotic patients have impaired judgment and insight, which are both intact for patient W.P.N. DSM-5 rules out personality disorder in this patient as he had a normal social life prior to the illness.

Obsessive-compulsive disorder with differentials of depression, phobic disorder and anorexia nervosa. However, DSM-5 rules out depression since depression has no recurrent, persistent urges, images, or thoughts or attempts to ignore or suppress the urges, images, or thoughts with another action or thought (APA, 2013). Obsession and compulsion are also absent in phobic disorder and anorexia nervosa.

Reflections:

If conducting a session with this patient again, what I would conduct differently is managing the recreational marijuana use. Marijuana is linked to a variety of disorders, such as cannabis hyperemesis syndrome, clinical depression, or worsening existing mental disorders. Thus, I would encourage the patient to join a support group to help curbing cannabis use, thus preventing the worsening of the current mental disorders. This step is in accordance with the ethical principle of beneficence and non-maleficence that promotes a positive outcome while minimizing harm to the patient. Also, I would persuade W.P.N. to discuss his mental condition with his family so that they can offer him vital support, which is indispensable to his recovery (Goodman et al., 2021). Owing to his past veteran service, encouraging him to join other ex-soldiers recovering from PTSD, anxiety, or OCD would speed up his recovery as they would share valuable experiences.

Case Formulation and Treatment Plan: 

The psychotherapy for PTSD includes cognitive therapy, whose rationale is assisting the patient to recognize patterns of thinking that exacerbate the illness. The nurse should educate the patient to avoid the fear that the traumatic event will happen again (Lewis et al., 2020). Exposure therapy will help the patient face the terrifying memories to promote effective coping. Virtual reality may allow W.P.N. to re-enter the war environment and safely handle the flashbacks (Lewis et al., 2020). Antidepressant medications such as sertraline and paroxetine will be equally beneficial in treating PTSD.

The psychotherapy for anxiety disorder includes cognitive behavioral therapy that equips the patient with specific skills to improve the symptoms while gradually resuming previously avoided activities. DeMartini et al. (2019) demonstrate that CBT gradually exposes the patient to the situation that triggers anxiety to create confidence, allowing managing both situation and anxiety symptoms. Medication for anxiety includes benzodiazepines such as midazolam and beta blockers such as propanolol that relieve the symptoms in the short term (DeMartini et al., 2019). Buspirone is also effective against anxiety, as well as antidepressants such as paroxetine, escitalopram and sertraline. Patient education would entail developing self-esteem and objective problem-solving techniques.

Regarding OCD, the appropriate psychotherapy would be exposure and response prevention, a CBT variant. The psychotherapist gradually exposes the patient to the obsession and instructs him to avoid performing the compulsions, easing the distress (Goodman et al., 2021). The point of education for the patient is to list the objects or events provoking fear, beginning with the simplest. According to Goodman et al. (2021), the patient learns to deal with the lesser fears as he works towards the major concerns. Medication for OCD includes fluvoxamine, fluoxetine, paroxetine, sertraline and clomipramine.

NRNP 6665 Comprehensive Focused Soap Note References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. (5th ed.)

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

Fasnacht, J. S., Wueest, A. S., Berres, M., Thomann, A. E., Krumm, S., Gutbrod, K., … & Monsch, A. U. (2023). Conversion between the Montreal Cognitive Assessment and the Mini‐Mental Status Examination. Journal of the American Geriatrics Society, 71(3), 869-879. https://doi.org/10.1111/jgs.18124

Goodman, W. K., Storch, E. A., & Sheth, S. A. (2021). Harmonizing the neurobiology and treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 178(1), 17–29. https://doi.org/10.1176/appi.ajp.2020.20111601

Lewis, C., Roberts, N. P., Andrew, M., Starling, E., & Bisson, J. I. (2020). Psychological therapies for post-traumatic stress disorder in adults: Systematic review and meta-analysis. European Journal of Psychotraumatology, 11(1), 1729633. https://doi.org/10.1080/20008198.2020.1729633

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