NRNP Focused SOAP Note Chapter

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NRNP/PRAC & 6675 Comprehensive Focused SOAP Psychiatric Evaluation TemplateWeek (enter week #): (Enter assignment title)Student NameCollege of Nursing-PMHNP, Walden UniversityNRNP 6665: PMHNP Care Across the Lifespan IFaculty NameAssignment Due DateSubjective:CC (chief complaint):The client is a 14-year old white female who is brought by her parents for refusing to eat, leading to generalized weakness, severe weight loss, and amenorrhea for four months. The parents are worried because the client has had a regular 26-28 day menstruation cycle since she began menarche aged 12. They fear that she could be pregnant although three tests carried out at home have all been negative.HPIThe client’s parents report that she has been dieting since seven months prior to the visit and that the condition began when her friends teased her about her greedy appetite and plumpness. As a result, she had stared restricting her food intake, engaging routinely in excessive exercises, and avoiding food high in fat. She frequently misses breakfast and lunch, and during dinner, she secretly puts food in a plastic bag and throws it in the dustbin. The client denies inducing purging or vomiting, but she perceives herself as ‘fat’. She is unhappy with her self image and believes that she is not pretty. The client is the oldest of two siblings and describes her parents as overprotective and strict. She feels that her father is excessively controlling and never allows her to make independent decisions. She reports being unable to be her real self as she is forced to live according to her father’s wishes. She admits having difficulty communicating with her younger sister and father, but believes that her mother understands her. Her parents describe her as a perfectionist and a lady obsessed with punctuality and cleanliness. Academically, she is above average and the family history is not indicative of mental illness or eating disorders. A few weeks before the visit, the client experienced epigastric pain that was accompanied by vomiting, joint aches, headaches, and severe fatigue. Her PCP prescribed antiemetics and multivitamins that helped to improve symptoms. The client denies having a boyfriend or involvement in sexual activity.Substance Current Use:Medical History:· Current Medications: None· Allergies: No Known Allergies· Reproductive Hx: LMP was four months agoROS:· GENERAL: The client denies chills and fever, although clinical tests show low blood pressure (hypotension) and bradycardia. Clinical examination reveals a thin girl with a height of 1.47m, weight of 28kg, and BMI of 13kg/m3, which reflects a 13 percent deficit in weight for her height.· HEENT: Eyes: No Visual Loss, blurred vision, double vision, or yellow sclerae; Ears, Nose and Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat· SKIN: No itching or rash, although skin was generally dry· CARDIOVASCULAR: No chest tightness, palpitations or edema· RESPIRATORY: No shortness of breath, cough or sputum· GASTROINTESTINAL: no stomach cramps, indigestion, constipation, or heartburn· GENITOURINARY: No burning on urination, hesitancy, or odd color· NEUROLOGICAL: Occasional headaches and dizziness, but no change in bladder or bowel control.· MUSCULOSKELETAL: Generalized muscle weakness· HEMATOLOGIC: No signs of bleeding, anemia or bruises· LYMPHATICS: Nodes are of normal size· ENDOCRINOLOGIC: client denies experiencing cold, profuse sweating, or heat intolerance.

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No polyuria or polydipsia .Objective:Diagnostic results:An electrocardiogram (EKG) test and chest x-rays were ordered to rule out cardiac conditions as potential causes of the client’s hypotension (Khairani et al., 2011). The clinician additionally ordered a complete blood count (CBC) to exclude medical conditions such as anemia and hyperthyroidism, which have similar presentations and could also account for amenorrhea and the frequent headaches and dizziness (Khairani et al., 2011). Results of the blood investigation were within normal limits. A urine…

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…a lower risk of suicidal thoughts in pediatric patients as compared to other SSRIs (Gordon & Melvin, 2014). At the same time, Olanzapine has been associated with a high risk of orthostatic hypotension, particularly during initial dose titration (FDA 2014). The client’s bradycardia poses as a risk factor in this case, necessitating proper clinical monitoring for cardiovascular changes (FDA, 2014). When used as prescribed, however, the combination treatment is expected to correct distorted thoughts about body shape in 4 to 6 weeks (FDA, 2014).Discussed Risks of Mixing Medication:The safety of co-administering Olanzapine and Fluoxetine at high dosages above 18mg and 75 mg respectively has not been evaluated in pediatric patients (FDA, 2014). This indicates a need for proper monitoring for adverse effects during maintenance therapy (FDA, 2014).Client has Emergency Numbers:The client was advised to contact the healthcare provider or call 911 in case of emergency or if she experiences suicidal thoughts, seizures, or tardive dyskinesia (FDA, 2014).Time Allowed for Questions and Answers:Questions were asked throughout the interview as a means of obtaining subjective information and at the end to test the client’s understanding.Follow-Up with PCP:The role of the PCP is to assist in the management strategies of the treatment team by assessing medical complications and monitoring weight and nutritional status (Khairani et al., 2011). The PCP will assess for the presence of any complications related to hypotension, endocrine abnormalities, seizures, kidney dysfunction, electrolyte imbalance, and amenorrhea (Khairani et al., 2011). Referral to other specialists should be indicated if these complications occur (Khairani et al., 2011). .Labs Ordered or Reviewed:Undesirable alterations in lipids have been observed with the use of Olanzapine and the FDA recommends appropriate clinical monitoring of fasting lipids (FDA, 2014). Fasting blood sugar tests were thus ordered to obtain baseline levels before treatment commenced.Return to Clinic: Client to return….....

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