Patient a 54-year-old African American male presents for medication management follow up appointment for depression.

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

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

Student Name

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): “I was just coming to do what I got to do/me been messing up on my appointments…I got to do what I got to do.”

HPI: Patient a 54-year-old African American male presents for medication management follow up appointment for depression. He was initially prescribed Escitalopram 10mg which he finds was too strong, stating that caused daytime tiredness. Patient reports hx depression/anxiety/insomnia but overall stable on medication but grieving death of father 6/2021.

Past Psychiatric/Substance Use/Legal History:

Diagnoses/Symptoms/Behavior: psychiatric tx began in his 40s.

Hospitalizations – Denies

Drug use/Methods of Acquiring/Route of Use – Denies

Alcohol use – Denies

Tobacco/Vaping – Denies

Legal – Denies

Military – Denies

Trauma – denies emotional/physical/sexual/domestic violence/neglectful relationship/financially .

Medical History

· Current Medications: Elavil 100mg per day/ Escitalopram 10mg Daily

· Allergies: NKA

· Reproductive Hx: Heterosexual

ROS:

· GENERAL: Appears stated age, Obese, Disheveled, Alert

· HEENT: Normocephalic, atraumatic

· SKIN: No obvious rash or sores, warm, dry and intack

· CARDIOVASCULAR: Regular rate and rhythm. No murmur

· RESPIRATORY: lungs are clear to auscultation, respirations are non-labored

· GASTROINTESTINAL: Soft. Non tender. Non distended

· GENITOURINARY: Negative

· NEUROLOGICAL: Alert. CN II-XII intact. normal sensory observed. normal motor observed. normal speech observed. normal coordination observed. developmentally normal.

· MUSCULOSKELETAL: Normal ROM. normal strength.

· HEMATOLOGIC: Negative

· LYMPHATICS: Negative

· ENDOCRINOLOGIC: Negative

Objective:

Diagnostic results: N/A

Assessment:

Mental Status Examination: This individual is a 54 y/o African American Male who look like his stated age. Came for medication evaluation/management. He is disheveled in appearance. On interview pt notable eccentricity in behavior/tends to be concretely irrelevant in thinking/speaks in circumstantial manner/dwelling on past ruminating on issues relating to multiple MVAs 2007/still trying to get monetary compensation however, feels “the attorney didn’t do my case right” admits does not deal well with changes/preoccupied with “waiting for a wife” denies feelings of hopelessness/denies current or past s/h ideas. Denies current/past psychosis/mania. Endorses symptoms cause significant distress in social/interpersonal/academic/occupational and other areas of daily functioning – goal to continue treatment.

Dianostic Impression

· Major depressive disorder, recurrent, severe w/o psychotic behavior (ICD10-CM F33.2)

· GAD (generalized anxiety disorder) (ICD10-CM F41.1)

· Post traumatic stress disorder (F43.10)

Reflections:

Case Formulation and Treatment Plan: 

pt evaluated and based on history/presenting symptoms meets DSM-5 criteria for diagnosis(s) listed, the pt is currently stable/not in a psychiatric crisis/no imminent risk for harm to self/other and is able to remain in established environment with mutually agreed treatment plan/non-harm agreement/willingness & ability to access emergency services.

pt condition is chronic but has been maintaining adherent stability with combined medication/therapy. based on hx there are no identifiable biological predisposition/adverse childhood experiences as noted, pt exhibits some mild personality-type eccentricity but not significantly diagnosable. he exhibits stable ego-dyatonic emotional/intellectual insight/judgment. his prognosis remains favorable owing to his ego-dystonically verbalizes willingness to take actions. regarding stabilization/recovery pt’s treatment goals are to utilize integrative/collaborative approaches to: establish CBT/DBT/ACT/MET-type therapeutic alliance to promote positive self-concept/effective coping. mechanisms by utilizing core mindfulness/distress tolerance/emotional regulation/interpersonal effectiveness activities. pt verbalizes willingness to take actions regarding: understanding and managing co-morbid & co-occurring illness/disease process/symptom management/relapse prevention/recovery plan is to utilize integrative/collaborative approaches to: achieve thought/mood/behavioral stabilization while gaining true intellectual/emotional insight and judgment. pt agrees to continue the following medications/treatment., escitalopram 5 mg daily – depression, continue individual therapy.

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Diagnostic Impression:

· Major depressive disorder, recurrent, severe w/o psychotic behavior (ICD10-CM F33.2)

· GAD (generalized anxiety disorder) (ICD10-CM F41.1)

· Post traumatic stress disorder (F43.10)

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations ( demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

References

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

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