NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
College of Nursing-PMHNP, Walden University
PMHNP Across Lifespan II Pract-Winter 2022
CC (chief complaint): Attempted suicide
HPI: A.P. is an 24-year-old African American presenting with a chief complaint of attempted suicide. The patient was admitted for a cocaine overdose. The patient exhibits symptoms of short temper, irritability, mood swings, and intense anger. He also reports binge drinking and eating. The patient exhibits marked impulsivity and irrational behaviors. The patient's mother says he mainly talks about death and threatens to jump off the balcony. She also reports that A.P. has episodes of variable moods that last for a few hours. A.P. reports experiencing recurrent thoughts of suicide and feeling worthless.
A.P. dropped out of college and stayed at home with his younger brother, who is physically disabled. The patient also has a pattern of intense relationships that do not last long. He recently ended his intimate relationship abruptly. He also cut family ties with his father and step-siblings and avoids his extended family members and friends. Additionally, the patient is distressed and wishes his suicide attempt was successful. The patient has a previous history of attempted suicide. He has had several burns and cuts on his arms. A.P. has also tried harming his younger brother when angry. He reports reckless driving when unable to control his anger. The patient has a DUI report and was convicted of physical violence when drunk. He lost his first job due to binge drinking and irrational behaviors.
The patient was diagnosed with depression at 18 years old. He was under antidepressants but discontinued therapy and treatment seven months ago after quitting college. A.P. has a family history of bipolar disorder. His maternal grandmother had a history of anxiety and depression. The patient's maternal uncle has a history of cocaine abuse and died from an overdose. His father also smokes tobacco and has a history of diabetes. A.P. was exposed to unstable invalidating relationships in his childhood. He was raised by a single mother who had on-and-off intimate relationships. The patient also experienced abandonment at age 12. He reports temporarily living under foster care.
Substance Current Use: The patient smokes tobacco (2 packets per day) and abuses cocaine. He is also a binge drinker (7 bears per day). He has a history of marijuana abuse.
· Current Medications: The patient is currently not under any medication or psychotherapy.
· Allergies: The patient is protein intolerant and experiences hives, itching, and eczema. He reports milk, eggs, and peanut allergies. He is also allergic to pet dander and exhibits nasal congestion and uncontrollable sneezing. He has no known drug allergies.
· Reproductive Hx: The patient is sexually active. He has no child nor a history of vasectomy.
· GENERAL: The patient appears generally healthy. He denies general body pain, fatigue, and cognitive issues.
HEENT: The patient has a 2-year-old scar on his head and a lesion behind his neck. He denies any recent changes in vision, difficulty hearing, tinnitus or vertigo, throat discomfort, and airway congestion. The patient has red eyes and brown teeth.
· SKIN: The patient has pale skin and yellow stains on the nails and fingers. He also has self-injury scars on his left arm, palm, phalanges, and back neck.
· CARDIOVASCULAR: The patient denies any history of hypertension or other cardiac issues. He also denies any history of swelling of the extremities and unexplained fatigue.
· RESPIRATORY: He denies any history of respiratory diseases or breathing difficulty. He has no symptoms of coughing or wheezing.
· GASTROINTESTINAL: A.P. has no history of ulcerative colitis or GERD. He denies symptoms of abdominal pain, nausea, and vomiting. The patient has no complaints of constipation or diarrhea. He reports increased appetite and binge eating habits.
· GENITOURINARY: The patient has no history of genitourinary issues, dysuria, or bladder infections.
· NEUROLOGICAL: The patient has neurological dysfunction. He exhibits symptoms of dissociation and cognitive impairment.
· MUSCULOSKELETAL: The patient has good reflexes and remains alert. He has no history of musculoskeletal conditions. He reports pain in his left foot joint attributed to an attempted suicidal jump off the roof.
· HEMATOLOGIC: The patient has no complaints of nose bleeding. He has a history of blood clots in his limbs.
· LYMPHATICS: The patient has sharply edged and palpable lymph nodes. He has no complaints of swollen ganglia or pain during palpation.
· ENDOCRINOLOGIC: He has no history of hyperthyroidism
Diagnostic results: B.P.: 144/9 mmHg, Pulse: 72 bpm, R: 14 breaths/min, T: 98.6°F
Mental Status Examination: The patient has a pattern of irrational behaviors. He portrays risky habits and repeated suicide attempts and ideation. Additionally, the patient's debilitating symptoms and unhealthy behaviors affect his social life. He has made irrational decisions, such as quitting college and ending his family, friends, and intimate relationships. Furthermore, the patient is alert but has dissociation symptoms that affect his concentration. His history of differing treatments raises concerns about poor adherence to pharmacotherapy and psychotherapy.
Diagnostic Impression: A.P.'s primary diagnosis is borderline personality disorder. This diagnosis is relevant because the patient has a history of depression, a predisposing factor (National Institute of Mental Health, 2022). The patient also meets the DSM-5-TR diagnostic criteria for borderline personality disorder, which includes social instability, repetitive patterns of unstable relationships, several suicide attempts, and impulsivity (The Diagnostic and Statistical Manual of Mental Disorders, 2013). The patient has a history of suicide attempts and reports suicide ideation. Additionally, he has scars from self-injury and a past of causing harm to people around him. The patient also exhibits symptoms of irrational behavior, such as binge drinking, eating, and driving recklessly under the influence. He has also experienced abandonment and was exposed to an unstable relationship. Furthermore, the patient's symptoms have affected his social life and productivity.
The patient is likely suffering from depression. The rationale is that he has a previous diagnosis of depression and a family history of depression. Additionally, the patient deferred treatment seven months ago. He also reports distress, mood swings, and difficulty controlling anger and emotions. He also has chronic feelings of emptiness, worthlessness, and suicidal ideation. However, this diagnosis is ruled out because the patient does not meet the diagnostic criteria. A.P. does not experience depression episodes consecutively for at least two weeks (National Institute of Mental Health, 2021). The patient's symptoms of mood swings and angry outbursts only last for a few hours. He has no symptoms of mania or depression. Additionally, the patient has no persistent distress, and his clinical symptoms indicate personality issues such as irrational decision-making.
Another differential diagnosis is post-traumatic stress disorder. The patient exhibits symptoms of a short temper, intense anger, and irritability. He also has several suicide attempts and a history of substance abuse. The patient has self-injury scars and reports suicide ideation. Additionally, he has a family history of complete suicide and exposure to abandonment, and family instability. These traumatic events might have triggered the patient's reaction to distress. However, this differential diagnosis is ruled out because the patient has no symptoms of flashbacks, intrusive distressing memories, or nightmares that support the DSM-5-TR diagnostic criteria (Boelen, 2021). Additionally, the patient has no signs of depressive avoidance of traumatic event triggers.
If I could conduct the patient evaluation session, I would establish the impact of the patient's suicide attempts on his mental health. I would engage the patient in a pre-and post-trauma experience assessment to identify his perception of his upbringing and childhood. This approach is necessary to identify whether the patient's background contributes to his irrational behaviors and mental impairment. Additionally, I would engage the patient's family and partner to establish his reaction to distress and coping means. I would interview the patient's family to identify resources available to support his recovery and educate the family to monitor his mental health progress.
Case Formulation and Treatment Plan:
The patient has a history of depression and treatment deferment. Therefore, it is necessary to focus on restoring good mental health through psychotherapy to reduce the risk of depression exacerbation. I would recommend the patient to a psychotherapist to aid with coping with distress (Gartlehner et al., 2021). I can collaborate with the patient's primary care physician to provide emotional, psychological, and social support. I would also recommend the patient for cognitive group therapy. According to Gartlehner et al. (2021), this intervention can help the patient build good interpersonal relations and maintain family ties. The patient can also learn how to overcome suicide ideation and avoid self-harm and injury. I would also recommend the patient to psychiatric management, focusing on symptom-targeted pharmacotherapy (Gartlehner et al., 2021). This intervention can help the patient overcome his symptoms and control his moods and emotions.
Additionally, I can recommend the patient to a social support group. This intervention aims to help the patient deal with childhood traumas and abandonment. The patient can learn how to cope with distress and control anger from other people's experiences. Additionally, the patient can gain hope in life, avoid suicide attempts, regain self-worth and build self-esteem. Finally, I would prescribe fluvoxamine 50mg per day to help minimize the symptoms.
I would involve the patient's mother in the planning and implementation of the proposed care plan to improve patient adherence to medication and psychotherapy. Additionally, I can follow up with the patient to monitor his progress. These interventions can help the patient cope with the debilitating symptoms and help his family support him during recovery.
Boelen, P. A. (2021). Symptoms of prolonged grief disorder as per DSM-5-TR, post-traumatic stress, and depression: Latent classes and correlations with anxious and depressive avoidance. Psychiatry Research, 302, 114033.
Gartlehner, G., Crotty, K., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., … & Viswanathan, M. (2021). Pharmacological treatments for borderline personality disorder: A systematic review and meta-analysis. CNS drugs, 35(10), 1053-1067. doi.org/10.1007/s40263-021-00855-4
National Institute of Mental Health. (2021). Depression.
National Institute of Mental Health. (2022, April). Borderline Personality Disorder.
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013). Am Psychiatric Assoc, 21, 591-643.
© 2021 Walden University Page 1 of 3