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PRAC 6665 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation

PRAC 6665 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation

Subjective: “I have been experiencing sleep-related problems for the last two months.”

CC (chief complaint): A.X. is a 17-year-old male client that came to the unit with complaints of persistently experiencing poor quality and quantity of sleep for the last two months. The patient reported that he finds it difficult to fall asleep and maintain sleep. He also noted that his sleep duration is significantly reduced due to frequent night awakenings followed by failing to sleep. A.X. reported that the sleep problem was affecting significantly his academic performance. He finds himself dozing off in the afternoons at school due to a lack of adequate sleep from previous nights. He denied any use of sleep-enhancing medications.

HPI: The client reported that the issue started two months ago with worsening symptom and intensity.

Substance Current Use: The client denied any history of substance use or abuse.

Medical History: The client denied any history of hospitalization or surgeries.

 

  • Current Medications: The client is currently not on any medication.
  • Allergies: The client denied any history of food, drug, and environmental allergens.
  • Reproductive Hx: The client denied any history of sexually transmit
    PRAC 6665 Wk 9 Assignment 2 Focused SOAP Note and Patient Case Presentation
    PRAC 6665 Wk 9 Assignment 2 Focused SOAP Note and Patient Case Presentation

    ted infections. He is currently not dating. He denied any history of dysuria, urgency, and frequency.

ROS:

GENERAL: The patient is dressed appropriately, alert, oriented with no evidence of weight loss, fever, chills, weakness, or fatigue.

HEENT:  Eyes:  The patient denied eye pain and discharge.  He also denies hearing loss, sneezing, congestion, runny nose, or sore throat. He also denies difficulty in swallowing, lymphadenopathy, and difficulty in breathing. He denied headache and head trauma.

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SKIN:  The patient denies the presence of rash or itching.

CARDIOVASCULAR:  The patient denies chest pain, chest pressure, or chest discomfort. He also denies palpitations

PRAC 6665 Wk 9 Assignment 2 Focused SOAP Note and Patient Case Presentation
PRAC 6665 Wk 9 Assignment 2 Focused SOAP Note and Patient Case Presentation

or edema.

RESPIRATORY:  He denies shortness of breath, cough, or sputum.

GASTROINTESTINAL:  He denies anorexia, nausea, vomiting, or diarrhea. He also denies abdominal pain or blood.

GENITOURINARY: He denies burning on urination, increased urinary frequency and urgency, or changes in the color and smell of urine.

NEUROLOGICAL: He denies any history of dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. He also denies changes in bowel or bladder control.

MUSCULOSKELETAL: He denies muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC:  He denies anemia, bleeding, or bruising.

LYMPHATICS: He denies enlarged nodes. No history of splenectomy

PSYCHIATRIC:  He denies any history of depression or anxiety.

ENDOCRINOLOGIC: He denies sweating, cold, or heat intolerance. No polyuria or polydipsia

ALLERGIES: No history of drug, food, or environmental allergies.

Objective:

Diagnostic results: A.X. is experiencing sleep problems. The diagnosis of sleep problems often relies on physical examinations and history taking. Psychiatric mental health nurse practitioners obtain comprehensive histories from their patients to guide in diagnosis. Laboratory investigations that include thyroid function tests and complete blood count may be performed to rule out any medical conditions that may be contributing to the problem. History taking and physical examination results were remarkable for a sleep disorder. Laboratory investigations were unremarkable.

Assessment:

Mental Status Examination: A.X is a male patient that appears appropriately dressed for the occasion. He does not have any evidence of weight loss. However, he appears fatigued due to a lack of sleep the previous night. He does not demonstrate any abnormal behaviors that include tics and tremors. He is oriented to self, place, and time. He denies illusions, delusions, and hallucinations. He also denies suicidal thoughts, plans, and attempts. His thought process is future-oriented.

Diagnostic Impression:

Episodic Insomnia: A.X’s primary diagnosis is insomnia. The patient has symptoms that align with those of insomnia, as stated in DSMV. According to DSMV, patients are diagnosed with insomnia if they present with complaints of dissatisfaction with sleep quality or quantity. The symptoms that accompany the dissatisfaction include difficulties in initiating sleep, maintaining sleep, and early-morning awakening that is followed by the inability to fall asleep thereafter. The duration of the sleep problem should be at least three months. The problem should also cause significant distress or impairment in functioning, including a decline in academic, social, and occupational functioning. Patients may also report difficulty in sleeping despite the presence of adequate opportunities for sleep (Ma et al., 2018). The sleep problem should not be attributed to other causes such as medication use, medical conditions, and substance abuse. Insomnia is further classified into persistent, episodic, or recurrent insomnia. Patients with persistent insomnia experience symptoms for a least 1-month and less than three months. Those with persistent insomnia experience symptoms for three months or longer while recurrent insomnia has two or more episodes within a year (de Zambotti et al., 2018). A.X. has symptoms that relate to the above, hence, insomnia being the primary diagnosis.

Depression: Depression is a secondary diagnosis that may be considered for A.X. According to DSMV, patients diagnosed with depression present with several symptoms. They include symptoms of depressed mood and lack of interest or pleasure. The depressive symptoms include having a depressed mood almost every day, weight loss or gain, insomnia or hyper-insomnia, psychomotor retardation or agitation, fatigue, worthlessness or guilt, decreased concentration, and suicidal thoughts, plants, or attempts (Maurer et al., 2018). Depression is the least likely diagnosis for A.X. due to the absence of depressive symptoms, weight changes, and lack of pleasure or interest.

Hypothyroidism: The other secondary diagnosis that may be considered for the patient is hypothyroidism. Patients with hypothyroidism may experience sleep-related problems. They may raise complaints that include insomnia, sleep lapses, or hyperinsomnia that occurs daily. Sleep disorders occur due to the involvement of the endocrine system in the disease (Chen et al., 2019). Laboratory investigations were unremarkable for the patient. Therefore, hypothyroidism is the least likely cause of the client’s sleep problems.

Reflections: I believe that the right approaches to diagnose the client with insomnia were utilized. Comprehensive history taking and physical examination guided the development of the diagnosis. One of the things that I will do if I experience similar care in the future is performing polysomnography. I will request a sleep study to be performed on the client to develop an accurate diagnosis of the sleep problem. Polysomnography will also help in initiating and adjusting the client’s treatment plan (Rundo & Downey III, 2019). The patient was not followed up. The next plan of action is scheduling the client for a follow-up review after four weeks to determine treatment effectiveness.

Case Formulation and Treatment Plan: A.X. was initiated on individual psychotherapy. He was educated on the importance of sleep hygiene habits. They included avoiding distractors during bedtime, caffeine, alcohol, or smoking, and taking heavy meals close to bedtime. The client was also educated about the importance of not engaging in strenuous activities close to bedtime and developing a sleep routine. He was educated about the importance of keeping a diary of effective strategies that helped him achieve better sleep. The strategies would be used to promote consistent improvement in sleep quality and quantity. The client was guided on the use of relaxation techniques and stimulus control therapy (Dewald-Kaufmann et al., 2019; Ma et al., 2018). The client was scheduled for a follow-up visit after four weeks to determine the effectiveness of the adopted treatment. Pharmacological treatments will be initiated should the client return with a history of worsening insomnia symptoms.

References

Chen, J., Hou, S., Li, X., & Yang, J. (2019). Management of Subclinical and Overt Hypothyroidism Following Hemithyroidectomy in Children and Adolescents: A Pilot Study. Frontiers in Pediatrics, 7. https://www.frontiersin.org/article/10.3389/fped.2019.00396

de Zambotti, M., Goldstone, A., Colrain, I. M., & Baker, F. C. (2018). Insomnia disorder in adolescence: Diagnosis, impact, and treatment. Sleep Medicine Reviews, 39, 12–24. https://doi.org/10.1016/j.smrv.2017.06.009

Dewald-Kaufmann, J., Bruin, E. de, & Michael, G. (2019). Cognitive Behavioral Therapy for Insomnia (CBT-i) in School-Aged Children and Adolescents. Sleep Medicine Clinics, 14(2), 155–165. https://doi.org/10.1016/j.jsmc.2019.02.002

Ma, Z.-R., Shi, L.-J., & Deng, M.-H. (2018). Efficacy of cognitive behavioral therapy in children and adolescents with insomnia: A systematic review and meta-analysis. Brazilian Journal of Medical and Biological Research, 51. https://doi.org/10.1590/1414-431X20187070

Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and Diagnosis. American Family Physician, 98(8), 508–515.

Rundo, J. V., & Downey III, R. (2019). Polysomnography. Handbook of Clinical Neurology, 160, 381–392.