PRAC 6665 Week 3 Assignment 2; Focused SOAP Note and Patient Case Presentation
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Week 3: Focused SOAP Note and Patient Case Presentation Student Name College of Nursing-PMHNP, Walden University PRAC 6665: PMHNP Care Across the Lifespan I Practicum March 21, 2022 Subjective: CC (chief complaint): “ My mom tells me I am moody, we get in a lot of fights because of it”. HPI: The client is a 16-year-old female who presents with irritability, mood swings, and anger. She has been diagnosed with an eating disorder and major depressive disorder by primary care provider. The mother reports irritable and labile moods with impulsive outbursts, which began at around age eight when younger sibling was born. The client is labile, irritable, and believes mother is “making a big deal out of this." The mother reports client has received several behavior write-ups in school for disruptive behavior and verbally disrespecting teachers. Mother reports client goes from being angry to crying back to angry. Client agrees her moods fluctuate and reports “ I don’t know how to handle my emotions”. She reports self-harm by mode of cutting since the age of ten. Both client and mother report a history of hypomanic symptoms, staying up for lengthy periods and only sleeping for 3-4 hours lasting about a week, followed by very low moods and refusing to get out of bed and out of her room even on school days. Today, she reports high anxiety and depression. The mother reports client has been sleeping about 4hrs for the past couple of weeks and is having poor focus and concentration. Client states she has poor appetite and has not been eating much. Mother reports client has been argumentative and has physically threatened mother. Client believes “ my mom is so exaggerated” and thinks that both teachers and mother are overreacting. The client is minimally cooperative with the assessment and hostile toward her mother. She denies hallucinations, suicidal and homicidal ideations. Substance Use History: Client denies. No family history of drug abuse. Current Medications: Drospirenone 3mg Tab PO daily, Acne. Allergies: NKDA Reproductive Hx: Onset of menses- 12 years of age. LMP 03/10/22. Denies sexually active. ROS: GENERAL: About 5lb weight loss in 6 weeks, no fever, chills, weakness, or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: Anorexia, no nausea, no vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: No burning on urination, urgency, hesitancy, odor, odd color NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness,......... Continue
