NUR 6665 Week 9: SOAP
Note
NUR 6665
Week 9:
SOAP Note
Lori Sfakios
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Dr. Michelle Pinckney
Subjective
Initials: L.R.
CC: “I am so irritable. My meds aren’t working”
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
, NUR 6665 Week 9: SOAP
Note
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.
Psychiatric History
• Hospitalizations- hospitalized in 2017 for making threats to kill a student in her school;
6/2018 for suicidal ideations and homicidal ideations toward mother; 7/ 2019 for suicidal
ideations with plan to overdose; 5/2020; no history of suicide attempts.
• Diagnosed with disruptive dysregulated mood disorder, generalized anxiety disorder,
attention-deficit hyperactivity disorder, and dyslexia.
• Intensive outpatient treatment 8/19 and 6/2020
• Multisystem family therapy in 2019
Medication Trials
• Adderall-”does not work, makes my moods worse”
• Lamictal-rash
• Latuda-gastrointestinal upset; “made me sick”
• Abilify-mother reports no effect on mood and behaviors
• Risperidone- mother reports no effect on mood and behaviors
•
Note
NUR 6665
Week 9:
SOAP Note
Lori Sfakios
College of Nursing-PMHNP, Walden University
PRAC 6665: PMHNP Care Across the Lifespan I
Dr. Michelle Pinckney
Subjective
Initials: L.R.
CC: “I am so irritable. My meds aren’t working”
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
, NUR 6665 Week 9: SOAP
Note
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.
Psychiatric History
• Hospitalizations- hospitalized in 2017 for making threats to kill a student in her school;
6/2018 for suicidal ideations and homicidal ideations toward mother; 7/ 2019 for suicidal
ideations with plan to overdose; 5/2020; no history of suicide attempts.
• Diagnosed with disruptive dysregulated mood disorder, generalized anxiety disorder,
attention-deficit hyperactivity disorder, and dyslexia.
• Intensive outpatient treatment 8/19 and 6/2020
• Multisystem family therapy in 2019
Medication Trials
• Adderall-”does not work, makes my moods worse”
• Lamictal-rash
• Latuda-gastrointestinal upset; “made me sick”
• Abilify-mother reports no effect on mood and behaviors
• Risperidone- mother reports no effect on mood and behaviors
•
