SOAP NOTE on Mental Health Disorders

Interval History: ” I took my mother’s car out again without her permission and crashed it again”.  The patient was involved in a head-to-head collision the first time he took his mother’s car and drove without a license.  The patient came today to the outpatient clinic this morning for his medication and psychiatric follow-up appointment(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students). The patient was accompanied by his father who stated that the patient continues to be having behavioral issues at home due to moving in and out of his house and that of his mother. Father stated that DCP&P was involved due to allegations made by his son that he was trying to choke him. It was investigated and was not found credible, and the case was closed. The patient reports that he has not been compliant with his medications, recently started his medication (Strattera 40 mg) but has not been compliant with his other medications. The patient continues to be impulsive and has highly risky behavior and showed no remorse. Family dynamics are poor.  Mother and father are divorced, encouraged family therapy and for CMO to start seeking out of-home placement preferrable partial hospitalization. The patient’s behavior has been erratic.  He got involved in several fights in school.  He crashed his mother’s twice within less than a year.  He doesn’t have a driver’s license.  The first time he crashed the car, 8 points were already applied to his future driver’s license.  He showed no remorse. He stole money from his parents, and his stepmother. He got involved in several fights in school, skipped school, and had no regard for other people.  He doesn’t see anything wrong with his behavior.  Problem Pertinent Review of Symptoms/Associated Signs and Symptoms: Psychotic, depressive, and anxiety symptoms are denied. Exam: Mood is labile.  The patient doesn’t like to be told what to do.  He reported feeling angry when his parents reprimand him.  Cognitive functioning, based on vocabulary and fund of knowledge, is commensurate with his age and abilities. He is oriented to time and place and can remember recent and remote events. Insight and judgment are generally poor.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

Attention-deficit hyperactivity disorder, predominantly inattentive type, F90.0 (ICD-10) (Active) Social phobia, unspecified, 312.81 (F91.1) Conduct Disorder, Childhood-Onset Type: (Active)

#1) Start Abilify 2 mg PO QHS

#2) Prozac 20 mg PO QAM

#3) Start Strattera 40 mg PO (ADHD)

#4) Vistaril 25 mg PO BID PRN

COMPREHENSIVE PSYCHIATRIC EVALUATION NOTE AND PATIENT CASE PRESENTATION, PART 1

Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient. (Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

·       PRAC_6645_Week7_Assignment2_Pt1_Rubric

PRAC_6645_Week7_Assignment2_Pt1_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomePhoto ID display and professional attire

5 to >0.0 pts

Excellent

Photo ID is displayed. The student is dressed professionally.

0 pts

Fair

0 pts

Good

0 pts

Poor

Photo ID is not displayed. Students must remedy this before a grade is posted. The student is not dressed professionally.

5 pts

This criterion is linked to a Learning OutcomeTime

5 to >3.0 pts

Excellent

The video does not exceed the 8-minute time limit.

3 to >0.0 pts

Good

The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)

0 pts

Fair

0 pts

Poor

5 pts

This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

10 to >8.0 pts

Excellent

The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

8 to >7.0 pts

Good

The video accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

7 to >6.0 pts

Fair

The video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis, but is somewhat vague or contains minor inaccuracies.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

6 to >0 pts

Poor

The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

10 pts

Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students

Subjective:

CC (chief complaint): ” I took my mother’s car out again without her permission and crashed it again”. 

HPI: JV is a 16-year-old male who came to the outpatient clinic this morning for his medication and psychiatric follow-up appointment. He is in the company of his father, who stated that the client has persistent behavioral issues, moving in and out of his house and that of his mother. The client reports taking his mother’s car without permission and crashing it. He had previously been involved in a head-to-head collision the first time he took his mother’s car and drove without a license. A report by the father indicates that the DCP&P had been involved in the client’s case following an allegation that he had strangled his son, trying to choke him. These allegations were, however, refuted as they were found incredible, and the case was closed. The client reports a lack of compliance with medications. Recently, he started Strattera 40mg and has not been compliant with other medications. The client is impulsive, involved in risky behavior, and shows no remorse. The client’s behavior has been erratic, getting involved in several fights in school and crashing his mother’s car twice in less than a year. The client reportedly stole money from his parents and his stepmother. He skips school and has no regard for other people. The client does not see anything wrong with his behavior. The client does not like to be told what to do, and he reported feeling angry when his parents reprimand him. (Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

Past Psychiatric History:

• General Statement: The client entered treatment at age 16 for psychiatric evaluation after having persistent behavioral issues. (Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)
• Caregivers (if applicable): Parents.
• Hospitalizations: No previous hospitalization reported.
• Medication trials: No medication trials were reported.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)
• Psychotherapy or Previous Psychiatric Diagnosis: Diagnosed with Attention-deficit hyperactivity disorder, predominantly inattentive type, F90.0 (ICD-10) (Active) Social phobia, unspecified, and 312.81 (F91.1) Conduct Disorder, Childhood-Onset Type: (Active). The client is not compliant with medication, and the behavioral issues are persistent.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

Substance Current Use and History: Denies alcohol or substance abuse. Denies abuse of illicit substances.

Family Psychiatric/Substance Use History: Denies family history of psychiatric disorder or substance abuse.

Psychosocial History: Family dynamics are poor. The parents are divorced. The clients move in and out of the father and mother’s homes. The client is in grade 10.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

Medical History:

• Current Medications: Strattera 40 mg PO (ADHD); Abilify 2 mg PO QHS; Prozac 20 mg PO QAM; Start Strattera 40 mg PO (ADHD); Vistaril 25 mg PO BID PRN.
• Allergies:NKFDA
• Reproductive Hx:NA

Objective:

ROS:

GENERAL: No weight loss, fever, chills, or fatigue.                               

HEENT: Eyes: No visual loss. Ears, Nose, Throat: No hearing loss, nasal congestion, or sore throat.

SKIN: No rash or itching.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

CARDIOVASCULAR: No chest pain, pressure, or discomfort.

RESPIRATORY: No breathing complications, cough, or sputum.

GASTROINTESTINAL: No abdominal pain or constipation. No nausea, vomiting, or diarrhea.

GENITOURINARY: No dysuria or hematuria.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

NEUROLOGICAL: No numbness, slurred speech, or ataxia.

HEMATOLOGIC: No easy bruising or bleeding.

LYMPHATICS: No painful or swollen nodes.

ENDOCRINOLOGIC: No polyuria of polydipsia.

Diagnostic results:

Physical Exam: NA

Assessment:

Mental Status Examination: The client is a 16-year-old male who looks his age. He denies psychotic, depressive, and anxiety symptoms. His mood is labile. He has appropriate knowledge and vocabulary corresponding with his abilities and age. He is oriented to time and place. His memory is recent. Insight and judgment are generally poor. The client denies suicide or homicide ideation.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

Differential Diagnoses:

1. Oppositional Defiant Disorder, 313.81 (F91.3) –  ODD is characterized by irritable/angry, defiant/argumentative, and vindicative behavior that lasts for at least six months and affects social and academic, or occupational behavior. Anger or irritability symptoms include temper outbursts, touchiness, or resentfulness/anger (APA, 2019). Argumentative/defiant symptoms include argumentative behavior, defiance of requests, deliberate annoyance, and blaming others for their own mistake. Vindicative symptoms include spitefulness.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)
2. Conduct Disorder, 312.81 (F91.1), Childhood-Onset Type – The diagnostic criteria for conduct disorder include violating people’s fundamental rights and societal rules and norms. Individuals present at least three symptoms over the past twelve months, one of which should be present in the past six months. Individuals show aggression toward others and animals, such as bullying, threatening, or intimidating others, initiating physical fights, causing physical harm, cruelty to others and animals,  stealing and confronting others, and forceful sexual activities (APA, 2019). Destructive behavior includes engaging in setting fire or destroying others’ property. Theft and deceit include breaking into people’s property, stealing non-trivial items, or conning others. Individuals stay out late with parental prohibition, run away from home, and are truant from school.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)
3. Antisocial Personality Disorder, 301.7 (F60.2) – The diagnostic behavior for APD include a persistent pattern involving violation or disregard for other people’s rights. Symptoms include failure to abide by social norms in terms of behavior leading to arrest; deceitfulness, such as lying or conning others; lack of planning ahead/impulsivity, aggressiveness/irritability through involvement in physical fights/assaults; disregard for other people’s safety, irresponsibility, lack of remorse. An individual must be at least 17 years of age to be diagnosed with APD.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

Reflections:

The client shows symptoms that meet the ODD diagnosis. The client is impulsive and is involved in risky behavior. He is not remorseful of his actions. He is erratic and gets involved and engaged in fights in school. He crashed his mother’s car twice a year, stole money from his parents and stepmother, keeps moving in and out of his parent’s house. He skips school and has no regard for other people. He does not feel anything wrong with his behavior. The client does not want to be told what to do and reported feeling angry when his parents reprimand him. ODD is more prevalent in males than females before adolescence, and no predominance is observed during adolescence (Wheeler, 2020). Lack of tolerance and emotional reactivity are predictors of ODD. Child neglect or harsh childhood increases the risks of ODD.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

Case Formulation and Treatment Plan:  

Pharmacology: Start Abilify 2 mg PO QHS. Low doses of Abilify is well tolerated and effective in treating ODD symptoms (Safavi et al., 2016).

Psychotherapy: Recommend family therapy. ODD affects the entire family, and family therapy teaches family members communication and coping skills (Hood et al., 2015). Specifically, parent-child interaction therapy would help children and clients communicate with each other and foster practical parental skills (Boland & Verdium, 2019).(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

Education: Encouraged family therapy and CMO to seek out-of-home placement, preferably partial hospitalization. Poor parenting increases ODD (APA, 2019). Therefore, the parent should be educated on better parental practices is crucial for appropriate general well-being and mental health outcomes. (Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7^th ed.). American Psychiatric Publishing, Inc.   

Boland, R., & Verduin, M. (2021). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins.

Hood, B. S., Elrod, M. G., & DeWine, D. B. (2015). Treatment of childhood oppositional defiant disorder. Current Treatment Options in Pediatrics, 1(2), 155-167. https://doi.org/10.1007/s40746-015-0015-7

Safavi, P., Hasanpour-Dehkordi, A., & AmirAhmadi, M. (2016). Comparison of risperidone and aripiprazole in the treatment of preschool children with disruptive behavior disorder and attention deficit-hyperactivity disorder: A randomized clinical trial. Journal of Advanced Pharmaceutical Technology & Research, 7(2), 43. https://doi.org/10.4103%2F2231-4040.177203

Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. Springer Publishing Company.(Comprehensive SOAP NOTE on Mental Health Disorders for Nursing Students)