Week 9: SOAP Note Student Name College of Nursing-PMHNP, Walden University PRAC 6665: PMHNP Care Across the Lifespan I Dr. Michelle Pinckney Date: …. Subjective Initials: L.R. CC: “I am so irritable. My meds aren’t working” HPI: The client is a 15-year-old female who presents with irritability, mood swings, and anger and is to be seen after being started on medications for her irritable and labile moods. She has been diagnosed with disruptive mood dysregulation disorder, attention-deficit hyperactivity disorder, and generalized anxiety disorder. She also has a learning disability, dyslexia. The mother reports irritable moods and explosive outbursts began around age eight when mother and father divorced. The client is labile, irritable, and "wants med changes." The mother reports her homeschooling is not going well, and she is "very moody and irritable, and her anxiety is high". The mother says that her moods fluctuate from high energy to depression. Client and mother report a history of hypomanic symptoms and staying up for lengthy periods and only sleeping for 3-4 hours, followed by crashing with depression. Today, she reports high anxiety and depression "sometimes". The mother reports, "she does not go to bed until after midnight lately, and then I have to fight to get her up to do schoolwork." Mother describes her daughter as "entitled". She finds her daughter to have an over-inflated sense of self, and her daughter feels she does not have to abide by any rules. The client reports going to sleep around 2am and getting up around 8 am. The client reports Intuniv helps but "doesn't last." She has been prescribed gabapentin but not taking it as prescribed. She is prescribed gabapentin three times daily and only takes 1-2 times a day. She occasionally misses doses of her Symbyax. When the client is asked why she does not take her medications as scheduled, she states, "I just forget". The client is minimally cooperative with the assessment and hostile toward her mother and this writer. She denies suicidal and homicidal ideations. Psychiatric History •Hospitalizations- hospitalized in 2017 for making threats to kill a student in her school; 6/2018 for suicidal ideations and homicidal ideations toward mother; 7/ 2019 for suicidal ideations with plan to overdose; 5/2020; no history of suicide attempts. •Diagnosed with disruptive dysregulated mood disorder, generalized anxiety disorder, attention-deficit hyperactivity disorder, and dyslexia. •Intensive outpatient treatment 8/19 and 6/2020 •Multisystem family therapy in 2019 Medication Trials •Adderall-”does not work, makes my moods worse” •Lamictal-rash •Latuda-gastrointestinal upset; “made me sick” •Abilify-mother reports no effect on mood and behaviors •Risperidone- mother reports no effect on mood and behaviors • Family Psychiatric/Substance Abuse •Mother-depression; no substance abuse history Substance Current Use: Client reports smoking cannabis “few” days a week Medical History: None •Current Medications: oSymbyax 6mg-25mg oGabapentin 100mg three times daily oIntuniv ER 3mg by mouth daily •Allergies: Lamictal •Childhood Immunizations: up to date •Developmental delays: none; began walking at 11 months; first words at 13 months; toilet trained at 3 years •Reproductive Hx: oOnset of menses-11 years of age olast menses two weeks ago oNot currently sexually active, mother reports possible sexual activity at age 13 when she was secretly dating an 18-year-old Psychosocial History The client is a single Caucasian female and an only child. She grew up in a household with her mother and father until age 8, when her parents divorced. She has lived with her mother full time and sees her father every other weekend.......... Continue