NRNP 6665 PMHNP Care Across the Lifespan I
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Name: P.P DOB: 1/07/1995 Age: 25 yrs Gender: female
Subjective:
CC (chief complaint): mood cycles between periods of low energy for about 4 to 5 times in a year, and mostly being high for more than a week in a row.
HPI: the patient came for a mental health assessment, and seeking review of her medications after being treated for previous psychiatric symptoms and being started on medications. She has a history of being treated using medications such as Zoloft, Risperidone, Seroquel (quetiapine), and Clonazepam, then stopping due to side effects. She reports getting episodes of low energy, no motivation, disinterest in activities 4 to 5 times a year. During these low periods, she often skips work, and eats too much, and prefers to sleep mostly up to 12 to 16 hours a day. She reports having periods that she is high for over a week, whereby she sometimes has auditory hallucinations. Excessive talking, insomnia for days, increased goal-orientedness, and heightened sexual behavior. The conversation also revealed she has grandiosity and a heightened sense of importance whereby she envisions everything about her future being with celebrity stars.
Past Psychiatric History: history of several admissions or psychiatric symptoms, she has had no suicidal or homicidal ideation since 2017.
Family Psychiatric History: her mother suffered from a psychiatric illness which she thinks was either bipolar and she tried committing suicide once. Her father went to prison for drugs and thinks her brother probably also has been diagnosed with a psychiatric problem before.
Legal History: she has been arrested once for public disturbance, but thinks this was made up because she cannot remember that scene
Substance Current Use: she smokes one packet of cigarettes daily, and has no recent history of other prescription drugs or substance abuse.
Medical History: he has hypothyroidism and polycystic ovarian syndrome (PCOS)
- Current Medications: takes thyroxines for hypothyroidism and oral contraceptive pills for PCOS
- Allergies:no known food or drug allergies.
- Reproductive Hx: heterosexual female but has a heightened sexual life at different times which places her at high risk.
Review of systems (ROS):
- GENERAL: no fever, night sweats, or vomiting, but amidst to have gained weight when taking some psychotropic medications
- HEENT: no changes in visual acuity, no diplopia, eye discharge, or photophobia. She has no ear pain, tinnitus, or discharge. No history of nose bleeding, recurrent upper airway infections, she has no denture or teeth problems, and reports of good oral hygiene.
- SKIN: normal hair texture and pigmentation, no nodules, ulcers, or lesions.
- CARDIOVASCULAR: she has no paroxysmal nocturnal dyspnea, intermittent claudication, palpitations or chest pain.
- RESPIRATORY: no exertion or difficulty in breathing, hemoptysis, or coughing.
- GASTROINTESTINAL: she has a good appetite, no changes in bowel habits, no nausea, vomiting, heartburn, dysphagia, yellowness of eyes, or abdominal pain.
- GENITOURINARY: no urinary urgency, incontinence, hematuria, frequency, hesitancy, dysuria, color changes, or decreased urine output.
- NEUROLOGICAL: No changes in memory, convulsions, syncope, lightheadedness, abnormal sensations, or dizziness.
- MUSCULOSKELETAL: no changes in gait or mobility, no joint aches, swelling, fractures, or history of arthritis or gout.
- HEMATOLOGIC: no bloody or dark stool, no easy bruising, or nosebleeding.
- LYMPHATICS: no peripheral edema, or swellings
- ENDOCRINOLOGIC: she has no polyuria, polydipsia, or constant polyphagia. She, however, reports slowness and a history of current treatment for hypothyroidism.
Objective:
Physical Exam
General: He was well-groomed, seemed overweight, and normal gait.
Vital signs: BP 123/78; pulse 81 regularly regular, temperature 37.5 ear; RR 21; weight: 142lbs; height 5’2; BMI 26 (overweight).
The rest of the systemic examination was normal.
Diagnostic results: awaiting results of her lipid profile.