Respond?at least?2 times?each to?all colleagues who presented this week (should be 2-3 presenters each week). The goal is for the discussion forum to function as rob

Week (enter week #9): (Focused SOAP Note)

Eduasvy VanBokklen

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan I

Dr. Donna Brunson

July 26, 2023

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Subjective:

CC (chief complaint): "I am super anxious about the baby"

HPI: R.S. is a 25 y/o female pt relates that she is feeling good but she is nervous about the baby because the baby is measuring 2 weeks smaller than it should be and they have not heard a heartbeat. She will be having a repeat ultrasound today. She reports that she is not feeling depressed. Pt reports that she is having a lot of fluctuation of her anxiety between a 6-9 on a rating scale. She would like to increase her Lamictal to 100mg. Pt reports that she understands the possibility that she may lose this pregnancy. She states that if she gets bad news today she will be able to call on friends for support until her husband is able to get back home since he is out of town on business. Reported to the pt that I spoke to her OB/GYN and she supports pt remaining on her medications due to benefits outweighing risks.

Educated patient on the options regarding medication and pregnancy related to the patient's symptoms and discussed risk versus benefits of medications while pregnant and alternatives such as safer medications or therapy. Patient educated on the risk of specific psychotropics in the first trimester considering fetal development, and the 3rd trimester, concerning birth, as well as breastfeeding.

Discussed options of stopping medication completely, switching the medication, and/or tapering down or discontinuing during specific trimesters, considering the ongoing assessment of the risk vs. benefits throughout pregnancy and breastfeeding. Advised patient to read the medication insert to fully understand risks pertaining to the specific medication and advised patient to contact office or talk to the pharmacist surrounding further questions. Discussed the need for close monitoring in collaboration with OBGYN to ensure safety. Thoroughly reviewed fact sheet from www.mothertobaby.org on Lamictal, Effexor and Wellbutrin with pt. Answered all questions she had regarding her medications. Pt relates that she has not been in touch with a therapist at this time but wishes to start with one who may have experience with women's issues including eating disorders and pregnancy. Referred pt to Amanda Morgan at Lime Counseling.

Substance Current Use: Denies tobacco, alcohol, and any substance abuse.

Past Psychiatric History:  General Statement: Multiple outpatient psychiatrists/therapists throughout her lifetime.  Caregiver: psychiatrist reports saw provider just once

 Hospitalizations: Denies

 Medication Trials: Remeron (did not like how she felt), Trazodone (did not feel a difference), Gabapentin (Suicidal thoughts), Propranolol (asthmatic)

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 Previous psychiatric diagnosis : never been officially dx but told she has: anxiety, bipolar 2, depression, ptsd, eating disorder, OCD, post-partum depression stress disorder

Medical History: Lupus, Ehlers Danlos Syndrome POTs, Asthma

 Current Medications: Imuran 150mg a day (for lupus), Plaquenil 400mg a day, Proair- albuterol

 Allergies: Bactrim

 Reproductive Hx: 1 previous pregnancy

ROS:

 GENERAL: GENERAL: No weight loss, fever, or fatigue.  F HEENT: wears glasses, no hearing loss

 SKIN: No rashes or itching.

 CARDIOVASCULAR: No chest pain, Hx of palpitations r/t POTs

 RESPIRATORY: hx of SOB r/t Asthma

 GASTROINTESTINAL: No abdominal pain, nausea, or vomiting.

 GENITOURINARY: No urinary symptoms or sexual concerns.

 NEUROLOGICAL: hx of headaches followed by PCP

 MUSCULOSKELETAL: hx of myalgia r/t lupus

 HEMATOLOGIC: No bleeding or bruising.

 LYMPHATICS: No enlarged lymph nodes.

 ENDOCRINOLOGIC: No excessive sweating or heat intolerance.

Objective:

Diagnostic results: PHQ-9: >20: Major Depression, severe GAD-7: 15-21: Severe anxiety

Assessment:

Mental Status Examination: Ms. R.S. is a 25-year-old Hispanic female who appears neat and appropriately dressed. Her speech is normal rate and rhythm, easily understandable as she

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engages in conversation with good eye contact. Her thought processes are logical‚ coherent‚ and goal directed. Her mood "good", "anxious" and affect is congruent. She is alert & oriented x4, denies any auditory or visual hallucinations with no evidence with delusional thinking and good insight.

Diagnostic Impression:

1. The client, Ms. R.S., fulfills the diagnostic criteria for Generalized Anxiety Disorder (GAD), as classified under DSM-5-TR: 300.02. She displays excessive worry and anxiety regarding various events or activities. Her health and pregnancy are her primary concerns. This anxiety is challenging for her to manage. Symptoms like restlessness, fatigue, and irritability are linked with her anxiety (DeMartini et al., 2019). She rates her anxiety levels fluctuating from 6 to 9 on a scale. This anxiety and associated physical symptoms cause significant distress. It impairs her ability to function in social, occupational, and other essential areas of life.

2. Ms. R.S. also has a reported history of Bipolar II Disorder, which leads to its inclusion as a diagnosis, as defined in DSM-5-TR: 296.89. However, she did not show prominent symptoms during the recent assessment. These symptoms typically include at least one major depressive episode, at least one hypomanic episode, and no full manic episodes (Marzani & Neff, 2021). Despite not being a primary concern now, her psychiatric history indicates that this disorder might be present.

Differential Diagnoses:

1. Ms. R.S.'s reported history indicates that she has Obsessive-Compulsive Disorder (OCD) as classified under DSM-5-TR: 300.3. But during the recent evaluation, she did not display notable symptoms such as obsessions, compulsions, or both. These symptoms cannot be attributed to the physiological effects of a substance or another medical condition (Starcevic et al., 2020). Hence, while OCD may exist in her psychiatric history, it is not currently the main concern.

2. Post-Traumatic Stress Disorder (PTSD), as classified under DSM-5-TR: 309.81, was also considered due to Ms. R.S.'s reported history. However, she did not display substantial symptoms during the current evaluation. Such symptoms would include exposure to actual or threatened death, severe injury, sexual violence, or presence of intrusion symptoms related to the traumatic event(s). This would be accompanied by persistent avoidance of stimuli related to the traumatic event(s), negative alterations in cognitions and mood related to the event(s). Further, there would be signs of marked alterations in arousal and reactivity related to the traumatic event(s) (Imbriano et al., 2022). Therefore, while PTSD may be part of her psychiatric history, it is not the main concern currently.

Rationale for Diagnostic Impression: The evidence supports a primary diagnosis of Generalized Anxiety Disorder (DSM-5-TR: 300.02) for Ms. R.S. Her excessive worry and anxiety about various events or activities, notably her health and pregnancy, which she struggles to control, upholds this diagnosis (Inness et al., 2022). The inclusion of Bipolar II Disorder in the diagnostic

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impression is influenced by her psychiatric history, even if it is not the main concern now. The lack of significant alternative primary psychiatric symptoms, like obsessive-compulsive or post- traumatic stress features, further reinforces the primary diagnosis of Generalized Anxiety Disorder.

Reflections:

I agree upon reflection that Ms. R.S. fulfills the diagnostic criteria for Generalized Anxiety Disorder and, considering her psychiatric history, Bipolar II Disorder. The data collected from her history, mental status examination, and diagnostic findings validate these diagnoses. This case accentuates the intricate relationship between mental health disorders and the stresses related to significant life events, such as pregnancy.

This case has enriched my comprehension of the difficulties experienced by people dealing with anxiety disorders. These difficulties can be exacerbated by significant life events and other health conditions. The case underlines the significance of a thorough, patient-focused approach that considers the unique situations and requirements of the individual.

Additionally, this case emphasizes the value of considering the entire psychiatric history of the patient when creating a diagnostic impression. Certain conditions (Bipolar II Disorder in the current case) may not be the primary concern at the assessment time. Still, they continue to be a crucial part of the patient's overall mental health profile.

Patient education and collaboration with other healthcare providers is essential; the case makes that abundantly clear. Making certain that the patient understands the risks and advantages of their medication is essential. This is particularly true during delicate periods like pregnancy. Additionally, collaboration with other healthcare providers, such as the patient's OB/GYN, can aid in delivering the most comprehensive and effective care to the patient.

Case Formulation and Treatment Plan:

Based on the primary diagnosis of Generalized Anxiety Disorder and Ms. R.S.'s unique needs, the proposed case formulation and treatment plan are as follows:

1. Medication Management: Ms. R.S. is to maintain her current psychotropic medications. These include Lamictal 100mg PO QD, Wellbutrin XL 300mg PO QD, and Effexor ER 150mg per day. The effectiveness of these medications and potential side effects will be monitored closely. Changes in dosages may be made depending on her treatment response and symptom progression.

2. Individual Psychotherapy: Ms. R.S. will be directed to a therapist who has expertise in women's issues. These include eating disorders and pregnancy. Cognitive Behavioral Therapy (CBT) will be especially useful in managing her symptoms of anxiety. This therapy will assist her in recognizing and contesting negative thought patterns and developing more effective coping strategies.

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3. Health Promotion Activity: Ms. R.S. will be advised to participate in regular physical activity. This could include walking or prenatal yoga, as approved by her OB/GYN and tolerated by her. Regular physical activity can assist in reducing symptoms of anxiety and enhancing overall well-being.

4. Patient Education: Ms. R.S. will continue to receive education about her medications. This includes potential risks during pregnancy and breastfeeding. She will also be educated about the symptoms of her mental health conditions and strategies to manage these symptoms.

5. Coordinated Care: Working closely with Ms. R.S.'s OB/GYN is essential to provide comprehensive care and tackle potential medical problems related to her mental health conditions or pregnancy. Consistent communication and sharing of treatment progress, including modifications to medication, will be maintained to optimize her overall care.

6. Social Determinants of Health: Ms. R.S.'s mental health justifies a recommendation to a social worker or case manager. They can help in identifying and addressing any social or environmental elements that might be contributing to her anxiety. This could include financial stress or insufficient social support.

7. Alternative Therapies: Ms. R.S. will be encouraged to explore alternative therapies. Mindfulness meditation or relaxation techniques are options that can help manage her anxiety symptoms. These therapies can be used in combination with her medication and psychotherapy.

8. Regular Follow-up: Regular follow-up visits will be planned to evaluate treatment progress, monitor response to medication, deal with any emerging issues, and offer ongoing support. If necessary, adjustments to the treatment plan will be made based on her changing needs and progress in managing her anxiety.

Objectives:

1. Following my presentation, my colleagues will acquire the skill to identify the primary symptoms of Generalized Anxiety Disorder.

2. Upon the completion of this presentation, my colleagues will gain the capability to articulate a comprehensive treatment plan for a patient with a Generalized Anxiety Disorder diagnosis.

3. This presentation's conclusion will equip my colleagues with knowledge. They will learn how pregnancy can impact a patient's mental health states and affect the treatment approach.

4. Comprehending the significance of taking into account a patient's complete psychiatric history while forming a diagnostic impression will also be a skill they will gain. At the completion of this presentation, this understanding will be theirs.

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Questions:

1. Which specific strategies would you suggest for managing anxiety symptoms during pregnancy?

2. Which assessment tools would be most suitable for a patient like Ms. R.S., who is pregnant and possesses a complicated psychiatric history?

3. What community resources would you recommend assisting Ms. R.S. throughout her pregnancy and in managing her mental health conditions?

4. How would you approach educating a patient like Ms. R.S. about the risks of medication during pregnancy?

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

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References

American Psychiatric Association. (2023). Diagnostic and statistical manual of mental disorders

(5th ed., text rev.). American Psychiatric Publishing.

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of

internal medicine, 170(7), ITC49-ITC64.

Imbriano, G., Waszczuk, M., Rajaram, S., Ruggero, C., Miao, J., Clouston, S., … & Mohanty, A.

(2022). Association of attention and memory biases for negative stimuli with post-

traumatic stress disorder symptoms. Journal of anxiety disorders, 85, 102509.

Inness, B. E., McCabe, R. E., & Green, S. M. (2022). Problematic behaviours associated with

generalized anxiety disorder during pregnancy and the postpartum period: A thematic

analysis. Psychology and Psychotherapy: Theory, Research and Practice, 95(4), 921-

938.

Marzani, G., & Neff, A. P. (2021). Bipolar disorders: evaluation and treatment. American family

physician, 103(4), 227-239.

Starcevic, V., Eslick, G. D., Viswasam, K., & Berle, D. (2020). Symptoms of obsessive-

compulsive disorder during pregnancy and the postpartum period: A systematic review

and meta-analysis. Psychiatric Quarterly, 91(4), 965-981.