PRAC 6675: PMHNP Across the Lifespan II<\/p>\n
Week 4: Case Study<\/p>\n
Objectives:<\/p>\n
Identify the signs and symptoms of three different psychiatric disorders.
\nExplore psychopharmacology that may help with the treatment plan.
\nExamine the diagnostic criteria from the DSM-5 that can help lead to a diagnosis.
\nSubjective:
\nChief Complaint (CC): “I think I have schizophrenia.”
\nHistory of Present Illness (HPI): MS is a 14-year-old Caucasian female who came to the clinic with her mother. She reports that she has been experiencing depression and anxiety for the past three years, which started when she was bullied at school. She reports a depression score of 8 out of 10 and experiences anxiety every day. She also reports having psychotic episodes, during which she sees “shadow people” and hears sounds with some words, but also states, “it’s my voice inside.” She reports experiencing paranoia and intrusive thoughts of harming herself that she cannot stop. She also reports dissociation and depersonalization. She has a history of cutting, skin picking, and eyebrow pulling. Additionally, her and her mother report that she has poor relationships, hates people, is impulsive, and is not happy. She states, “it is my psychosis that makes me see and believe things that aren’t real, and I feel very disconnected from reality.”
\nPast Psychiatric History:
\n\u2022 General Statement: Anxiety and depression starting three years ago. Autistic Spectrum Disorder.
\n\u2022 Caregivers (if applicable): Parents
\n\u2022 Hospitalizations: Two inpatient hospitalizations for suicidal ideation and self-harming.
\n\u2022 Medication trials: Geodon, Lithium, Prozac, Zoloft, Zyprexa, and Wellbutrin. (Doses and side effects unknown).
\n\u2022 Psychotherapy or Previous Psychiatric Diagnosis: Sees a therapist once a week for Dialectical Behavioral Therapy (DBT). Previously diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder.
\nSubstance Current Use and History: Denies
\nFamily Psychiatric\/Substance Use History: Depression and anxiety in mom, dad, and one brother. Grandmother with substance use disorder and suicide attempt.
\nPsychosocial History: MS was born and raised in Michigan by both parents. She lives with both parents and three older brothers. She recently switched from an in-person art school to a virtual school and is currently in 9th grade. She has a 504 plan for school. Her hobbies include music, drums, and guitar. She reports being bullied in school. She denies any legal history.
\nMedical History:
\n\u2022 Current Medications: Seroquel XR 100mg QD, Buspar 5mg BID
\n\u2022 Allergies: Penicillin (vomiting)
\n\u2022 Reproductive Hx: Not sexually active.
\nReview of Systems (ROS):
\n\u2022 General: Denies fever, chills, or weakness.
\n\u2022 Head, Eyes, Ears, Nose, Throat (HEENT): No trauma to head. Denies visual loss, blurred vision, or double vision. Denies hearing loss, congestion, sore throat, or runny nose.
\n\u2022 Skin: No rash or itching.
\n\u2022 Cardiovascular: Denies chest pain, pressure, or discomfort. Denies palpitations.
\n\u2022 Respiratory: Denies shortness of breath, cough, or difficulty breathing.
\n\u2022 Gastrointestinal: Denies vomiting or diarrhea. No abdominal pain.
\n\u2022 Genitourinary: Denies burning on urination.
\nReferences
\nAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https:\/\/doi.org\/10.1176\/appi.books.9780890425596
\nCeranoglu, T., Wozniak, J., Fried, R., Galdo, M., Hoskova, B., DeLeon Fong, M., Biederman, J., & Joshi, G. (2019). A retrospective chart review of buspirone for the treatment of anxiety in psychiatrically referred youth with high-functioning autism spectrum disorder. Journal of Child and Adolescent Psychopharmacology, 29(1), 28\u201333. https:\/\/doi.org\/10.1089\/cap.2018.0021
\nGillespie, C., Murphy, M., Kells, M., & Flynn, D. (2022). Individuals who report having benefitted from dialectical behaviour therapy (dbt): A qualitative exploration of processes and experiences at long-term follow-up. Borderline Personality Disorder and Emotion Dysregulation, 9(1), 1\u201314. https:\/\/doi.org\/10.1186\/s40479-022-00179-9
\nNational Institute of Mental Health. (n.d.). Suicide prevention. https:\/\/www.nimh.nih.gov\/health\/topics\/suicide-prevention
\nRiffer, F., Farkas, M., Streibl, L., Kaiser, E., & Sprung, M. (2019). Psychopharmacological treatment of patients with borderline personality disorder: Comparing data from routine clinical care with recommended guidelines. International Journal of Psychiatry in Clinical Practice, 23(3), 178\u2013188. https:\/\/doi.org\/10.1080\/13651501.2019.1576904
\nU.S. Department of Health and Human Services. (n.d.). Reduce suicide attempts by adolescents. https:\/\/health.gov\/healthypeople\/objectives-and-data\/browse-objectives\/mental-health-and-mental-disorders\/reduce-suicide-attempts-adolescents-mhmd-02<\/p>\n","protected":false},"excerpt":{"rendered":"
PRAC 6675: PMHNP Across the Lifespan II Week 4: Case Study Objectives: Identify the signs and symptoms of three different psychiatric disorders. Explore psychopharmacology that may help with the treatment plan. Examine the diagnostic criteria from the DSM-5 that can help lead to a diagnosis. Subjective: Chief Complaint (CC): “I think I have schizophrenia.” History […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2643,2580,2363,405,1301],"tags":[2943,2942],"class_list":["post-6070","post","type-post","status-publish","format-standard","hentry","category-comprehensive-soap-note-examples","category-help-writing-a-soap-note-case-study-assignment","category-help-writing-nursing-essay","category-soap-note-assignment-help","category-writing-a-soap-note-sample-answers","tag-prac-6675-pmhnp-across-the-lifespan-ii","tag-week-4-case-study"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/6070","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/comments?post=6070"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/posts\/6070\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/media?parent=6070"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/categories?post=6070"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/us\/wp-json\/wp\/v2\/tags?post=6070"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}