Sample Answer for NRNP 6665: PMHNP Across the Lifespan I: Assessing, Diagnosing, and Treating Adults With Mood Disorders -Comphrensive SOAP Note for Petunia Park Case Study

Subjective:

CC (chief complaint): “I am here for a mental health assessment.”

HPI:

Petunia Park is a 27-year-old female client who presents for a mental health assessment. She mentions that she has a history of taking medications and failing to adhere to them because she thinks she does not need them. She feels that the meds squash her. Petunia also states that she has a history of falling into depression 4-5 times annually, which limits her from working at her aunt’s bookstore. When depressed, she sleeps a lot and has little to no motivation. She states that she lacks creativity when depressed leaving her feeling worthless. The depression comes after working hard for about five days on things she enjoys, like painting, writing, and music. Although people perceive that she has depression, Petunia thinks the sleepiness and lack of motivation are due to fatigue after several days of working hard.

Petunia reports that she is usually creative roughly a week before crushing. On her creative days, she declines to take her meds because they crush her and the lots of energy she has. She also sleeps for a few hours, does a lot of work, talks a lot, and seems scattered. Furthermore, the client reports engaging in sexual activity to explore her body and mind and get gratification. She is too busy to have meals when on the creative episodes but can eat everything when she crashes. She sleeps three hours a week when creative and 12-16 hours/per day when crushed. In addition, the client reports that when she has an inadequate sleep, she hears voices telling her that she is great and talented.

Substance Current Use: The last alcohol consumption was at 19 years. She admits to smoking 1PPD. She once used Marijuana, but it caused paranoia.

Medical History: Positive for Hypothyroidism

• Current Medications: Levothyroxine for Hypothyroidism; and Hormonal pills for Polycystic Ovaries.
• Allergies: None

• Reproductive Hx: Has Polycystic Ovaries.

ROS:

• GENERAL: Positive for increased appetite and low energy levels when depressed. Suppressed appetite and increased energy levels on creative episodes.
• HEENT: Denies headache or eye, ear, nose, and throat symptoms.
• SKIN: Denies skin symptoms.
• CARDIOVASCULAR: Negative for cardiac symptoms.
• RESPIRATORY: Negatives for difficulties in breathing.
• GASTROINTESTINAL: Negative for abdominal distress.
• GENITOURINARY: Negative for urinary symptoms.
• NEUROLOGICAL: Denies paralysis, headaches, or loss of consciousness.
• MUSCULOSKELETAL: Denies muscle, joint, or bone symptoms.
• HEMATOLOGIC: Denies bleeding.
• LYMPHATICS: Denies lymphatic symptoms.
• ENDOCRINOLOGIC: Denies endocrine symptoms.

Objective:

Diagnostic results: No lab tests were ordered.

Assessment:

Mental Status Examination: Female patient in her 20’s. She is neat and dressed appropriately for the function and weather. The client is alert and oriented and maintains adequate eye contact. Her speech is clear with normal rate and volume and logical. She demonstrates a coherent and logical thought process. Auditory hallucinations were reported, and delusions of grandeur were noted (states that she paints like Picasso and will sell paintings to movie stars). No evident suicidal ideations or thoughts. Her memory is intact, she demonstrates good judgment, and insight is present.

Diagnostic Impression:

Bipolar Disorder: Bipolar disorder presents with episodes of mania that alternate with depression. Petunia has manic episodes, which she refers to as creative episodes, which alternate with depressive episodes, whereby she feels crushed. She presents with clinical manifestations consistent with the DSM-V diagnostic criteria for mania, including a decreased need for sleep, more talkative than usual, grandiosity, distractibility, increase in goal-directed activity, and engagement in activities with a high potential for adverse consequences like engaging in sexual activity for gratification (APA, 2013). The patient’s manic episodes alternate with depressed episodes, where she has low motivation, low energy levels, hypersomnia, and increased appetite (Vieta et al., 2018).

Major Depression: Major depression is a mood disorder that manifests with a depressed mood and significantly diminished interest/pleasure in almost all activities (APA, 2013). Petunia reports having depression ep