PRAC 6665 Week 9 Assignment 2; Focused SOAO Note and Patient Case Presentation

HPI: The client is a 15-year-old female who presents with irritability, mood swings, and anger and is to be seen after being started on medications for her irritable and labile moods. She has been diagnosed with disruptive mood dysregulation disorder, attention-deficit hyperactivity disorder, and generalized anxiety disorder. She also has a learning disability, dyslexia. The mother reports irritable moods and explosive outbursts began around age eight when mother and father divorced. The client is labile, irritable, and "wants med changes." The mother reports her homeschooling is not going well, and she is "very moody and irritable, and her anxiety is high". The mother says that her moods fluctuate from high energy to depression. Client and mother report a history of hypomanic symptoms and staying up for lengthy periods and only sleeping for 3-4 hours, followed by crashing with depression. Today, she reports high anxiety and depression "sometimes". The mother reports, "she does not go to bed until after midnight lately, and then I have to fight to get her up to do schoolwork." Mother describes her daughter as "entitled". She finds her daughter to have an over-inflated sense of self, and her daughter feels she does not have to abide by any rules. The client reports going to sleep around 2am and getting up around 8 am. The client reports Intuniv helps but "doesn't last." She has been prescribed gabapentin but not taking it as prescribed. She is prescribed gabapentin three times daily and only takes 1-2 times a day. She occasionally misses doses of her Symbyax. When the client is asked why she does not take her medications as scheduled, she states, "I just forget". The client is minimally cooperative with the assessment and hostile toward her mother and this writer. She denies suicidal and homicidal ideations...