Psychiatric Evaluation

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Week 7 Grand Rounds Discussion: Complex Case Study Presentation

Student name: KA

College of Nursing-PMHNP

PRAC 6675: PMHNP Care Across the Lifespan II Practicum


Assignment Due Date :7/14/2021

Objectives for the Presentation

After this presentation:

· Objective 1

The audience will be able to list the diagnostic criteria of Bipolar I as per the DSM 5 definition.

· Objective 2

The audience will be able to list one FDA approved pharmacological treatment modality for the management of bipolar disorders.

Objective 3

The audience will be able to list one evidence -based psychotherapeutic treatment for the management of bipolar disorder.



(Chief complaint): ”I don’t know what’s going on with me. I hope you can help me feel better with my mood swings”.


CK is a 25-year-old African American female. She reports that she had a severe manic episode 1 month ago and was hospitalized at a local hospital. After this episode, she reports she was very depressed for a week. She has 2 small children and she said she called CPS and said she was overwhelmed and afraid she could not handle her kids anymore. She gave the kids to her aunt. The patient said her anxiety is 2/10 at this time and her depression is a 7/10. She was started on Lexapro 20 mg PO daily a month ago. she is also prescribed Vraylar 4.5 mg cap daily. She reports feeling better and denies mania currently. she denies SI/HI/AVH. she said she has good family support system. She is also willing to start therapy next week. The patient reported that she was diagnosed with depression, and bipolar disorder in the past.

Past Psychiatric History

The client has a history of bipolar disorder and Major Depressive Disorder(MDD). The patient recalls that when she was 15 and in high school, she had a period of time where she went as many as 5 days with very little to no sleep. She said during that time, she was very hyper and had racing thoughts and felt very irritable and “wired” with a lot more energy than usual. She said her mother recalled her changing boyfriends and having sexual indiscretions. She reports that her mother got worried and took her to the ER. \


She said she was started on medications but not she did not continue taking the medications and does not remember what the names of the medications. She denies Suicide Ideation, homicide ideation at present. The client shared those 2 or 3 times a year she has episodes where her mood is very depressed most of the days and she has feeling of interested in anything. She even reports during those times, she barely can sleep and lacks energy to do anything and stays in bed all day. She also reported during these depressive periods, she feels worthless and have difficulty concentrating during that same time.

Current Medications: The patient reports that she was started on Lexapro 20 mg PO daily a month ago. she is also prescribed Vraylar 4.5 mg cap daily. She reports these two medications seem to help her.

Psychotherapy: The patient has never tried psychotherapy. Swartz & Frank (2001)noted that although pharmacotherapy is the mainstay of treatment for bipolar disorder, medication offers only partial relief for patients. Treatment with pharmacologic interventions alone is associated with disappointingly low rates of remission, high rates of recurrence, residual symptoms, and psychosocial impairment. Bipolar-specific therapy is increasingly recommended as an essential component of illness management. Patient is willing to start psychotherapy next week.

Substance Current Use:

CK denies any past or current substance abuse .

Medical History:

Two C sections birth of her children.

Family Substance Use and Psychiatric History

Reports maternal Grandmother had a history of depression. And her mother has Bipolar. Father has history of alcohol use disorder. Her brother smokes marijuana and was in jail for conduct disorder.

Social History

Single, patient has two children, but they have been taken away by CPS and given to her aunt. She lives alone in her apartment and works at a local Starbucks. She owns her car and has health insurance. Currently her aunt has her two small children. She is taking classes part time at a local college and had to withdraw her summer term due to her recent hospitalization. She intends on continuing college when her mood is more stable. She reports dating a new boyfriend.

Allergies: The client did not report any allergies.

Reproductive Hx: patient reports a history of two pregnancies and two births The patient’s last monthly periods were last week. She denies being pregnant and she reports being sexually active.

Review of Systems (ROS)

• General: Denies weight loss or gain, fever, or chills. Denies fatigue.

• HEENT: Head: Denies headaches, head injury/trauma. Eyes: Denies visual loss, double vision, or yellow sclera. Ears: Denies hearing loss, ringing in the ears, or drainage. Nose: Denies sneezing, congestion, runny nose. Throat Denies itching, swelling, redness, or sore throat.

• Skin: Denies lesions, rash, itching, or easy bruising.

• Cardiovascular: Denies chest pain, chest pressure, or discomfort. No edema or palpitations.

• RESPIRATORY: Denies shortness of breath, cough, or sputum.

• GASTROINTESTINAL: Denies anorexia, denies nausea, vomiting, or diarrhea. No abdominal pain or blood.

• GENITOURINARY: Denies burning on urination. Pregnancy. The last menstrual period was last week.

• NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Denies seizures activities

• MUSCULOSKELETAL: Denies any trauma, injury, or pain.

• HEMATOLOGIC: Denies any history of anemia, bleeding, or bruising.

• LYMPHATICS: Denies any enlarged nodes. Denies history of splenectomy.

PSYCHIATRIC: Reports Major Depressive Disorder (MDD) . Reports Bipolar Disorder. Reports being hospitalized last month for a severe manic episode. Stated had another manic episode in her teens.

• ENDOCRINOLOGIC: denies hypothyroidism. Denies hyperthyroidism Denies any history of sweating, cold, or heat intolerance. No polyuria or polydipsia or thyroid disorder. Denies any diabetes.


• Food: No food allergies.

• No Environmental and Seasonal Allergies and Latex Allergy.


Physical Assessment:

• Vital Signs: not assessed

• General: She is alert and oriented and appears stated age. No weight loss or fever reported.

• Appearance: Normal appearance. She is well-developed. She is not diaphoretic.


• Head: Normocephalic and atraumatic.

Eyes: General: No scleral icterus. Right eye: No discharge. Left eye: No discharge.

Conjunctiva sclera: Conjunctivae normal. Nose: reports no drainage.

Neck: Normal range of motion.

Trachea: No tracheal deviation.

Cardiovascular: Rate and Rhythm: Normal rate.

Pulmonary: Pulmonary effort is normal. No respiratory distress.

Musculoskeletal: Normal range of motion.

Skin: General: Skin is warm and dry

Neurological: she is alert and oriented to person, place, and time.

Psychiatric: Attention and Perception: She appears attentive and alert and oriented.

Mood and Affect: Affect is flat and depressed.

Speech: Speech is clear.

Behavior: Behavior is calm.

Diagnostic results: There were no laboratory tests specific to diagnose BD. To diagnose BP. The PMHNP will conduct a thorough psychiatric history of the patient including family history as well as ask about current medical conditions that can affect the patient’s mood, I will order a urine drug screen because of my patient strong family history of use of alcohol and drugs. First, I will order CBC, chemistry profile , thyroid function tests, and B12 level to rule out metabolic causes or unidentified conditions . Johnson, Vanderhoef, & Johnson (2016). I will also order baseline EKG to make sure our patient does not have underling cardiac abnormalities before I order psychotropic medications. .

There are diagnostic tools to assist in assessing for BD. Second, I will use the Mood Disorder Questionnaire to assess for bipolar disorder. Hirschfeld et al (2010) noted that The MDQ is a self-report inventory that screens for a lifetime history of a manic or hypomanic syndrome by including 13 yes ⁄no items (Question 1). In addition to achieving the threshold number of symptom items, the subject must also have indicated that the symptoms clustered in the same period (Question 2) and caused moderate or serious problems (Question 3) (16, 21, 22). An MDQ screening score of ‡ 7, plus concurrence of symptoms and at least moderate problems reported, was found to have a sensitivity of 29–91% and a specificity of 67–94% for the diagnosis of bipolar disorder. I will also use the DSM-5 to help me in diagnostic inclusions and exclusions for this client. (APA,2013).

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