NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric

Evaluation Template

Week # 7 Comprehensive Psychiatric Evaluation


College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II


January11th, 2023


1. Perform a thorough complete psychiatric evaluation.

2. Choose the best possible primary diagnosis.

3. Analyze the best pharmacology and nonpharmacological Options 4. Provide community resources.


CC (chief complaint): “I’m here because my doctors and mom are worried about my mood. I’m always sad, overwhelmed, and anxious about my new baby and I cry often. I am struggling with this new baby.” HPI:

K.A. is a 16-year-old Hispanic female that presents to the office today with her mother for initial intake. The patient verbalized that she had a baby two months ago but has been suffering from sadness, hopelessness, guilt, and frequent crying. She reports that she felt sad and depressed when she found out she was pregnant but that the feelings of worthlessness and helplessness with periods of anxiety have increased since giving birth two months ago. She states “sometimes I don’t want to get out of bed to do anything but now this baby is making it difficult for me able to do what I want. She feels guilty for letting her family down because had big hopes for her. She reports that when the baby cries she gets tremors, increased heart palpitations, and sweating spells. She also complains of frequent headaches, body aches, and tension. Mom reports that she is concerned with the client’s well-being because she is sad and cries when she fails to take care of the baby. Sometimes she does not sleep because she thinks something will happen to the baby. The client’s mom reports that she has to remind her several times to take a bath and groom herself otherwise she can stay in her pajamas for days. She forgets to provide care for the baby and is scared and anxious when the baby cries. The client denies suicide ideation or hallucinations. She denies any alcohol or substance use. She denies any past psychiatric history. She denies any family psychiatric history or hospitalizations.

Substance Current Use: Patient denies substance use, alcohol or cigarette smoking

Past Psychiatric History: K.A denies any past psychiatric history or hospitalization

· General Statement: K.A. is sad, tearing up occasionally, and feels hopeless, worthless, withdrawn, and anxious at times.

· Caregivers (if applicable): Mother

· Hospitalizations: None

· Medication trials: K.A denies any medication history

· Psychotherapy or Previous Psychiatric Diagnosis: Denies any psychiatric history

Substance Current Use and History: Denies drugs, alcohol, and cigarette smoking.

Family Psychiatric: Denies any past psychiatric history or family history

Psychosocial History:

The client verbalized that she was in 10 th grade going to 11 th when she found out she was pregnant. She is still with her boyfriend but is currently not sexually active and not on any birth control . She reports that she is very tired all the time because the baby does not sleep at night and cries a lot. She misses her friends from school but their parents don't want them to play with her since they found out she was pregnant. Her cousins also no longer visit her. she reports that she no longer has any hobbies. She feels she has no time for herself. She lives with her mom and two younger siblings. Her father is not in her life, her parents got divorced when she was very young. Her only support system is her mother and boyfriend but her mother works long shifts and therefore can only offer limited help.

Medical History: Denies use of alcohol, drugs, or smoking

· Current Medications: Prenatal vitamins

· Allergies: Honey- nausea/ vomiting

· Reproductive Hx: Sexually active since 15 years old. Has a two-month-old baby.Is currently not sexually active since the birth of the baby. Not on birth control.


GENERAL:+Insomnia, fatigue, sadness, emotions with sobbing and periods of anxiety, no fever, chills, or weakness .

HEENT: Eyes: K.A. wears eyeglasses and contacts; she denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: K.A. denies rash or itching.

CARDIOVASCULAR: K.A. denies chest pain, chest pressure, or chest discomfort. + occasional palpitations and 1+ edema to bilateral feet due to pregnancy.

RESPIRATORY: K.A. denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: K.A. reports poor appetite, and denies nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: K.A denies burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: K.A. verbalized headaches, and denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: K.A. denies muscle, or back pain, joint pain, or stiffness.

HEMATOLOGIC: K.A. denies any anemia, bleeding, or bruising.

LYMPHATICS: K.A. denies enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: K.A. denies sweating, cold, or heat intolerance. No polyuria or polydipsia.


Diagnostic results:

B/P 130/76 Pulse 78 Respiration 18 Temp 98.9 F weight 150 lbs.

PHQ-9 assessment was completed and reviewed, score = 18, indicative of moderate-severe depression. Over the prior two weeks, the patient endorsed having problems with sleep, energy, and appetite nearly every day and interest and mood for several days. The patient denied having problems with suicidal ideation, or thoughts of self-harm over the past two weeks.

GAD-7 assessment was completed and reviewed in session, score = 14, indicative of moderate anxiety. The patient reported having anxiety and fear of something awful happening nearly every day, having uncontrollable worrying for more than half of the days, and having widespread worrying, trouble relaxing, and irritability for several days over the last two weeks. The patient denied having restlessness over the last two weeks.


Areas of stress included the following: severe stress due to family, relationship, and childcare concerns, moderate stress due to economic, occupational, and educational concerns, and mild stress due to nutrition concerns. There was no stress reported in the following areas: housing and legal concerns.


Mental Status Examination:

K.A. is a 16-year-old Hispanic Female that is two months postpartum and is age appropriate. She is alert and oriented x 4 with good insight and concentration but appears sad, emotional, and withdrawn with crying outbursts at times. K.A. is answering questions appropriately and is cooperative with the examiner. She is well-groomed, clean, and dressed appropriately for the season. She is fidgety and shifts her position in her chair often. Makes good eye contact and her speech is slow, soft monotone but clear with fluctuating tone and pitch. Her affect is congruent but sad.No pressured speech, flight of ideas, or looseness of association. The mood is sad, depressed, restless, and anxious. She denies any auditory or visual hallucinations or delusions. There is no evidence of any delusional thinking. She denies any current suicidal or homicidal ideation.

Diagnostic Impression:

Major Depressive disorder with Postpartum onset

Up to 80 percent of women who have given birth experience the "baby blues" or the "fourth-day blues''. Postpartum depression (PPD) is more severe and longer lasting. PPD can affect the The ability of the mother to care for her child and herself which is a potentially life-threatening physical and emotional condition characterized by depression-like symptoms that occur from a month to a year after childbirth and is thought to be caused in part by dramatic hormonal shifts that occur during childbirth (Piotrowski, 2021). The DSM 5 states that five (or more) of the following symptoms must be present at least one of which is either a depressed mood or lack of interest or pleasure-have appeared over the course of the same two-week period. Subjective symptoms include feelings of sadness, emptiness, hopelessness, or crying the majority of the time, almost every day with markedly lowered interest or enjoyment in practically all activities with the onset of childbirth (American Psychiatric Association, 2013). The patient met the diagnostic criteria for major depressive illness, according to the DSM 5. She complained of a change in her mood, a loss of interest in friends and almost all activities, weight gain, insomnia, and a lack of concentration. This is my primary diagnosis because the patient’s mood and behavior shifted after childbirth and the results of het PHQ-9.

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD) is a condition in which a person struggles with excessive and overwhelming worrying over anything small or big. The individual’s daily life must be impacted negatively by the presenting symptoms, which must manifest every day for at least six months according to the DSM 5(American Psychiatric Association, 2013). K.A. reported that her symptoms of worrying and panicking started when she found out she was pregnant and it has increased tremendously with the delivery of her baby. She states that she worries that something bad might happen to her or the baby especially when she falls asleep. The results of the GAD 7 conducted in session on this client yielded a result of 14 which is indicative of moderate anxiety. Her home, social, and school life have been negatively impacted by her symptoms of worrying, restlessness, sweating, and heart palpitation. She meets the DSM-5 criteria for the diagnosis of

generalized anxiety disorder according to the symptoms she is manifest Adjustment Disorder With mixed anxiety and depressed mood:

The DSM 5 describes adjustment disorder as the appearance of emotional or behavioral symptoms in reaction to a stressor within three months of the stressor's initiation. Clinically relevant manifestations of these symptoms or behaviors include one or both of the following taking into account the external context and any cultural elements that may have an impact on the degree and presentation of the symptoms, marked distress that is out of proportion to the severity or intensity of the stressor or significant dysfunction in social, academic, or other key aspects of functioning (American Psychiatric Association, 2013). A combination of depression and anxiety is predominant with adjustment disorder. K.A. has both the symptoms of depression and anxiety disorders, therefore, she satisfies this diagnosis. She repeatedly discloses how she is struggling to accommodate the baby and how she is failing to care for the baby.

Case Formulation and Treatment Plan:

My Preceptor and I reviewed the results of her assessments, PHQ-9 and GAD-7 were discussed with the client and her mother in session and were given the opportunity to ask questions. K.A. was given the option of medication and psychotherapy based on her results of PHQ9 and GAD 7 scores. The client declined all medication and insists that she wants to breastfeed, and does not want medication at this time. The medication of choice was Zoloft 50 mg because it is an effective SSRI and one of the few medications that are safe to be taken while breastfeeding (Molenaar, et al., 2018). Information on Zoloft was provided to her to think about it and can be discussed again at next week’s appointment. The patient was encouraged to start psychotherapy particularly cognitive-behavioral therapy (CBT) because it will help to lessen symptoms of depression and anxiety disorders (Beal, 2021). CBT will help K. A improves emotional regulation and creates specific coping strategies that are aimed at resolving her present issues of hopelessness, anxiety, and fear (Beal, 2021). K.A. was educated on post-postpartum blues and provided with information on Social support for new moms with postnatal education which is essential in terms of the prevention of future pregnancies and depression. The loving support of a spouse or partner, relatives, and close friends is extremely helpful ( Sprague, 2021). The client and mother agreed to devise a plan to help the client with the baby so she can get more sleep. Coping mechanisms were reviewed in sessions with proven steps to manage anxiety and mood. The special supplemental nutrition program called Women, Infants, and Children (WIC ) was given to clients because they offer to screen for depression and provide treatment referrals while teaching proper feeding techniques and strategies (Weinfield & Anderson, 2022).

K.A.‘s social determinants of health are quite a few because teenage pregnancy and births pose many challenges that require collective efforts to provide solutions. Efforts to reduce teen pregnancy are mainly focused on prevention, and sex education is a large part of the effort. Research shows that reducing the number of births to teens and increasing the age at which a woman gives birth yields significant cost savings (Piotrowski & Benson, 2022). The patient was referred to her OB /GYN for birth control measures because she is currently not on any birth control and is still dating her boyfriend. K.A. was given information on how to enroll in WIC to get assistance with nutrition for herself and the baby. She was encouraged to join a support group for teenage mothers. The patient was given a follow-up appointment in a week to think about all the information discussed in the session. She contracted for safety. A lab slip for a CBC, BMP, and TSH was given to the patient to complete before the next appointment. Instructed her to call the office with any questions or call 911 with any emergencies.

The Following Resources were Girven to the Patient:


I agree with the comprehensive and thorough assessment my preceptor conducted and I would not change anything. My preceptor did a great job engaging the patient in the whole treatment plan and process. The patient was given adequate information about the medication and nonpharmacological treatment options to arrive at her decision. At the beginning of the session, the patient and her mother gave informed consent to be treated and informed that everything discussed in the meeting will be kept confidential(Bipeta, 2019). It is vital that healthcare providers communicate with the patient in a manner that is nonjudgmental. It is equally important to remember that depending on the patient encounter the examiner might not be able to collect the global picture of the patient's history which includes social, genetic, and environmental factors (Saddock et al., 2015). My preceptor educated me that it is important to get as much information as possible but that not everything might be covered in the first meeting and that is why the next follow-up is in a week’s time. I learned that you have to give the patient adequate time to arrive at their decision. At the next follow up the patient stated that she was feeling much better after the first meeting with my preceptor and her first session with the therapist. She confirmed that she wants to continue breastfeeding her baby and will not be considering medication at this time.


1. Do you agree with my differential diagnoses? and if not, please provide your suggestion.

2. What is your opinion about the patient’s decision to refuse medication?

3. What other support and community resources would you offer this patient?


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Beal, D. G. (2021). Cognitive behavior therapy (CBT). Salem Press Encyclopedia of Health.

Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of

Psychological Medicine, 41(2), 108-112.

Carroll, C. M. (2021). Generalized anxiety disorder (GAD). Salem Press Encyclopedia of Health.

Community Support for Young Parents. (n.d.). HHS Office of Population Affairs. Retrieved January 10, 2023, from

Journal of the American Academy of Psychiatry and law. (n.d.). Document on principles of informed consent. Journal of the American Academy of Psychiatry and the Law.

Driessen,E., Van, H. L., Peen, J., Don, F. J., Twisk, J. W. R., Cuijpers, P., & Dekker, J. J.

M. (2017). Cognitive-Behavioral Versus Psychodynamic Therapy for Major Depression: Secondary Outcomes of a Randomized Clinical Trial. Journal of Consulting Clinical

Helping Teen Parents and Their Children Build Healthy Futures. (n.d.). HealthyChildren.Org. Retrieved January 10, 2023, from

Molenaar, N. M., Kamperman, A. M., Boyce, P., & Bergink, V. (2018). Guidelines on treatment of perinatal depression with antidepressants: An international review. Australian & New

Zealand Journal of Psychiatry, 52(4), 320–327.

Piotrowski, N. A., PhD, & Benson, A. K., PhD. (2022). Postpartum depression. Magill’s Medical Guide (Online Edition).

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11thed.). Wolters Kluwer.

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) | Food and

Nutrition Service. (n.d.). Retrieved January 10, 2023, from

Sprague, C. (2021). Teen Pregnancy. Salem Press Encyclopedia.

Weinfield, N. S., & Anderson, C. E. (2022). Postpartum Symptoms of Depression are Related to

Infant Feeding Practices in a National WIC Sample. Journal of Nutrition Education and Behavior, 54(2), 118–124. https://doi.org/10.1016/j.jneb.2021.09.002

© 2021 Walden University Page 1 of 9

© 2021 Walden University Page 1 of 9

© 2021 Walden University Page 1 of 9

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