The 3rd One. Due Tommorrow Respond to WAN NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template Respond to WAN Provide a res

The 3rd One. Due Tommorrow Respond to WAN NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Respond to WAN

Provide a response to 1 of the 3 discussion prompts that your colleagues provided in their Discussion presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.
2 citations and two references.

Week 7:

Sudent name : Wan

College of Nursing-PMHNP
PRAC 6675: PMHNP Care Across the Lifespan II

July 14, 2021

Objectives:

1. Identify the criteria for diagnosing a patient with Bipolar Disorder, current episode mixed, unspecified during the mental health assessment

2. Describe the reasons for my differential diagnosis?

3. Develop the best treatment plan that will benefit this particular patient

Subject

CC: Patient states, “I am here because I want to kill my family because they don’t include me in
anything”.

HPI: AM is a 15-year-old Caucasian female referred to the Bradley Center involuntary by
Rivertown psychiatry for homicidal thoughts, intent to kill her family, and auditory
hallucinations. The patient states that she went into her sister’s room while the sister was sleeping
and tried to cut a vein in her legs. The patient says, “that the voices told me to cut her and to take
my entire family out.” The patient states that after she killed her sister, her brother would be
next. The patient says that the knife did touch her sister’s leg before she awakens, making
superficial cuts. The patient states that if I kill them, my life would be better off. The patient says
that she has been hearing voices telling her to kill her family for about one month. The patient
has a history of major depressive disorder and psychosis.
Substance Current Use: No substance use

Medical History: No medical history

Past Psychiatric History-Greenleaf psychiatric facility November 2020 for suicidal thoughts.

Current Medications: Latuda 20mg daily for depression associated with bipolar disorder,
Lamictal 25mg daily

Allergies: NKDA
Reproductive Hx: None
ROS:
· GENERAL: No weight loss, fever, chills, weakness or fatigue

· HEENT: No visual loss, blurred vision, no hearing loss, congestion or runny nose

· SKIN: No rash or itching

· CARDIOVASCULAR: No chest pain, chest discomfort, chest pressure or edema

· RESPIRATORY: No shortness of breath or cough

· GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain

· GENITOURINARY: No burning, urgency, hesitancy, or odor

· NEUROLOGICAL: No headaches, dizziness or syncope

· MUSCULOSKELETAL: No back pain, joint pain or stiffness

· HEMATOLOGIC: No anemia, bleeding, or bruising

· LYMPHATICS: No history of splenectomy, no large nodes noted

· ENDOCRINOLOGIC: No sweating, cold or heat intolerance

Objective:

Vital Signs: B/P-98/58, HR-67, RR-20, T-36.9, O2 Sat-100%, HT-163.8cm, WT-65.4 kg

Diagnostic results: None

Assessment:

Mental Status Examination:

AM is a 15-year-old Caucasian female who looks her stated age. She is making good eye contact
and cooperative. She is dressed and groomed appropriately. There is evidence of psychomotor
retardation. Her thought process is goal-oriented and illogical. Her mood is depressed, and her
affect constricted and flat. At the time of the assessment, the patient reported having auditory,
command, and visual hallucinations of her family dead. There are homicidal thoughts present,
plan, and intent. The patient denies suicidal ideations. She is alert and oriented x 4. Her recent
and remote memory is intact. Her concentration is good. Her insight is impaired, and her
judgment is flawed.

Diagnostic Impression:

F31.60-Bipolar disorder, current episode mixed, unspecified- The criteria to be diagnosed
with bipolar disorder is there is a distinct period of abnormally and persistently elevated,
expansive, or irritable mood and abnormally persistently increased activity or energy, lasting at
least four consecutive days and present most of the day, nearly every day. The patient stated that
she had been hearing voices for the past 30 days and had thoughts of hurting her family. Mixed
features refer to the presence of high and low symptoms co-occurring, or as part of a single
episode, in people experiencing an episode of mania or depression. In most forms of Bipolar
Disorder, moods alternate between elevated and depressed over time (Hu, Mansur & McIntyre,
2014).

Differential Diagnosis:

F33.1 Major Depression Disorder-The criteria to be diagnosed with MDD, mood most of the
day, nearly every day. Diminished interest or pleasure in all, or almost all, activities most of the
day. Nearly every day (Mullen, 2018). The patient states that she wanted to kill her family
members due to the voices and never include her in activities. The patient has a history of MDD.

F41.1 Generalized Anxiety Disorder-The criteria for this diagnosis is excessive and
uncontrollable and irrational worry, that is, apprehensive expectation about events and activities.
This patient has been having irrational worrying when the family does not include her in the
Circumstances (Gale & Millichamp,2016). She probably doesn’t feel loved by her family. The
patient states that she does not have any friends or needs any friends.

Reflections: I agree with my preceptor’s assessment and diagnostic impression of Bipolar
Disorder, current episode mixed, unspecified. The patient came to the Bradley center with
command auditory and visual hallucinations and homicidal ideations with plan and intent. The
patient should be admitted as an inpatient to get stabilized on medication. The multidisciplinary
team needs to determine what has happened on the last inpatient admission. The team needs to
find out what has worked in the past to help this patient. This is a very delicate situation that
could affect the child and family for life. I would see if the patient has been in compliance with
the medications and educated the child and family on the importance of medication management.
If she is not taking the drug, I would see why. The patient could be having side effects of the
medication or if the medication needs to be adjusted or changed. Some health promotions are to
have patient engagement within their communities, school, organizations, peer groups, and
churches which are constructive. The community engagement would be constructive since the
adolescent states she doesn’t have any friends have any pleasure in doing anything. This will give
the teenagers opportunities to feel wanted and appreciated. Some ethical and legal situations are
that the child should be treated with respect and support at all times. Everyone must work
together to ensure that the child feels she belongs and is loved. While the child is in school, the
teacher must be vigilant about what is happening in the classroom. The teacher should engage
the adolescent with other adolescents by having group projects where communication is crucial.
The teacher should build rapport with the adolescent to ensure that it can be identified and
reported if the adolescent has issues such as abuse. The provider must understand the family’s
social and economic status due to the ability to afford the prescribed medication.

Case Formulation/Treatment Plan

The patient will be restarted on her Lamictal and Latuda. The patient will be started on Lamictal
25mg daily to stabilize her mood. Education will be provided to the child in the family that
Lamictal can cause drowsiness when first started. Some side effects of Lamictal are nausea,
insomnia, running nose, headache, diarrhea, abnormal dreams, dizziness, and tiredness. The
family should be educated on if the symptoms persist notify the provider (Carandang et al.,
2007). Latuda helps the child think more clearly, feel less nervous, and take part in everyday
life. It can also help with a decrease in hallucinations. Educate the patient and parents on the
importance of if the child is taking birth control pills; the medication could cause the drugs to be
less effective (Goldmen et al., 2017). The next plan is to see if the patient’s symptoms persist if
the child can live with another family member, so the child could be placed with someone shet

trusts and not be placed in another facility, such as residential. The child will need intensive
family therapy with wrap-around services through New Horizons to have a therapist come out to
the home until she becomes stable.

References

Carandang, C., Robbins, D., Mullany, E., Yazbek, M., & Minot, S. (2007, February).
Lamotrigine in adolescent mood disorders: a retrospective chart review. Journal of the

Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne
de psychiatrie de l’enfant et de l’adolescent.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276172/.

Diagnostic and Statistical Manual of Mental Disorders (DSM–5). DSM-5.

n.d.). https://www.psychiatry.org/psychiatrists/practice/dsm.

Hu, J., Mansur, R., & McIntyre, R. S. (2014). Mixed Specifier for Bipolar Mania and

Depression: Highlights of DSM-5 Changes and Implications for Diagnosis and Treatment in

Primary Care. The primary care companion for CNS disorders.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116292/.
Gale, C. K., & Millichamp, J. (2016, January 13). Generalised anxiety disorder in children and

adolescents. BMJ clinical evidence.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711893/.
Goldman, R., Loebel, A., Cucchiaro, J., Deng, L., & Findling, R. L. (2017, August). Efficacy and

Safety of Lurasidone in Adolescents with Schizophrenia: A 6-Week, Randomized Placebo-

Controlled Study. Journal of child and adolescent psychopharmacology.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5568017/.

Mullen, S. (2018, November 1). Major depressive disorder in children and adolescents. The
mental health clinician. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213890/.

Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013, June). The DSM-5: Classification and criteria

changes. World psychiatry : official journal of the World Psychiatric Association (WPA).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683251/.

Questions:

1. What happens when a decision has to be made in regards to the well-being of the child versus the safety of the siblings at home?

2. How can the family be protected from the patient when the voices come again?

3. What alternative living conditions can be provided for this family?

4. What kind of therapy would be beneficial for this family?

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