Impulse Control Disorder Comprehensive Psychiatric Evaluation SOAP note
Impulse Control Disorder Comprehensive Psychiatric Evaluation SOAP note
PRAC 6645: Psychopathology and Diagnostic Reasoning
Subjective:
CC: ” I have been unable to control my anger for quite a long time. My family also accuses me of lying. I feel so frustrated, but I cannot control myself.”
HPI: P.M. is a 47-year-old female client presenting with ongoing difficulties related to impulse control, mood instability, and sleep disturbances. She has been experiencing these features, which have strained her relationship with her family. The strained relationships with her family and close relatives. P.M. states that her family dislikes her, resulting in her angry outbursts and aggressive behavior. She describes experiencing persistent frustration, difficulty sleeping through the night, and having thoughts of self-harm or harming others when provoked. These symptoms have been worsening, leading to increased conflicts at home and significant distress.
Past Psychiatric History:
- General Statement: M. is a 47-year-old female experiencing significant impulse control issues, mood instability, and disturbed sleep patterns.
- Caregivers: Husband
- Hospitalizations: Denies past hospitalization episodes.
- Medication trials: She was previously on Sertraline but discontinued due to side effects.
- Psychotherapy or Previous Psychiatric Diagnosis: Previously diagnosed with Intermittent Explosive Disorder; attended individual therapy briefly in the past.
ORDER HUMAN-WRITTEN PAPER HERE
Substance Current Use and History: She has never used drugs or substances of abuse. Family Psychiatric/Substance Use History: Brother has a history of depression; no known substance use issues in the family.
Psychosocial History: Married; lives with husband and brother, who are her primary source of support. However, she reports ongoing family conflicts and difficulty maintaining stable relationships due to anger issues.
Medical History:
- Current Medications: Hypertension is managed with lifestyle changes; no other significant medical conditions have been reported.
- Allergies: None currently.
- Reproductive Hx: G2P2, no complications during pregnancies; currently postmenopausal.
R.O.S
- CONSTITUTIONAL: Reports difficulty sleeping; denies fever or weight changes.
- EYES: Denies vision changes, eye pain, or discharge.
- ENT: Denies hearing loss, tinnitus, sore throat, or nasal congestion.
- CARDIOVASCULAR: Denies chest pain, palpitations, or edema.
- RESPIRATORY: Denies cough, shortness of breath, or wheezing.
- GASTROINTESTINAL: Reports occasional nausea; denies vomiting, diarrhea, or constipation.
- GENITOURINARY: Denies dysuria, frequency, or hematuria.
- MUSCULOSKELETAL: Reports muscle tension; denies joint pain, stiffness, or swelling.
- NEUROLOGICAL: Denies headaches, dizziness, numbness, or seizures.
- PSYCHIATRIC: Reports mood instability, irritability, and thoughts of self-harm or harming others.
- SKIN: Denies rashes, lesions, or itching.
- ENDOCRINE: Denies heat/cold intolerance or changes in thirst or urination.
- HEMATOLOGIC/LYMPHATIC: Denies easy bruising, bleeding, or swollen lymph nodes.
- ALLERGIC/IMMUNOLOGIC: Denies allergies or immune system issues.
Objective:
- GENERAL: Alert and oriented, in no acute distress.
- HEAD: Normocephalic, atraumatic; no tenderness or abnormalities noted.
- EYES: Conjunctiva clear; pupils equal, round, and reactive to light.
- EARS: Tympanic membranes intact; no discharge or inflammation.
- NOSE: Nasal passages clear; no obstruction or discharge.
- MOUTH/THROAT: Oral mucosa moist; no lesions or signs of infection.
- NECK: Supple; no lymphadenopathy or thyroid enlargement.
- CARDIOVASCULAR: Regular rate and rhythm; no murmurs or gallops detected.
- RESPIRATORY: Lungs clear to auscultation bilaterally; no wheezes or crackles.
- ABDOMEN: Soft, non-tender; bowel sounds present; no distension.
- GENITOURINARY: External genitalia normal; no abnormalities noted.
- MUSCULOSKELETAL: Full range of motion; no joint swelling or deformities.
- NEUROLOGICAL: Cranial nerves II-XII intact; reflexes symmetrical and intact.
- SKIN: Warm, dry, and intact; no rashes or lesions.
- PSYCHIATRIC: Cooperative; affect appropriate; mood appears anxious and irritable.
Diagnostic results:
Psychiatric Assessments:
- Beck Depression Inventory (BDI): Moderate depressive symptoms reported.
- State-Trait Anger Expression Inventory (STAXI): Elevated scores indicating significant anger issues and difficulty managing impulses.
- Mini International Neuropsychiatric Interview (MINI): Positive for Intermittent Explosive Disorder.
Labs:
- Complete Blood Count (CBC): Within normal limits; no signs of anemia or infection.
- Thyroid Function Tests (TFTs): Normal; no indication of thyroid dysfunction contributing to mood symptoms.
- Basic Metabolic Panel (BMP): Normal electrolyte levels; renal function within normal range.
Others:
- Sleep Study (Polysomnography): Mild sleep apnea noted; disrupted sleep patterns confirmed.
- Substance Abuse Screening (AUDIT): Negative for alcohol use disorders; no substance abuse identified.
Assessment: Impulse Control Disorder Comprehensive Psychiatric Evaluation SOAP note
Mental Status Examination:
The patient appeared disheveled and had poor hygiene, consistent with her stated age. She exhibited agitated behavior during the interview, displaying impulsive movements and fidgeting. Her speech was pressured and rapid, making it challenging to interrupt, and she spoke with the normal tone and volume. P.M. reported feeling angry and frustrated, with a labile affect observed throughout the assessment. Her thought process seemed disorganized as she provided tangential responses. The content of her thoughts included themes of self-harm, along with feelings of worthlessness and paranoia regarding her family’s opinions of her. She denied experiencing hallucinations, and no delusions were observed. During the assessment, she is well-oriented to time, person, place, and situation. However, she had a limited attention span and impaired concentration. Her insight into her condition was a proper judgment of the underlying condition.
Differential Diagnoses:
Intermittent Explosive Disorder (IED) – ICD-10: F63.81: P.M. presents with features such as recurring anger outbursts and affecting her routine activities. The patient exhibits intense anger and violent behaviors when confronted, reflecting a failure to control aggressive impulses (Scott et al., 2020). These episodes lead to significant distress and impairment in relationships, aligning with the DSM-5-TR criteria for this disorder.
Major Depressive Disorder (MDD) – ICD-10: F32.1: MDD is defined by persistent feelings of sadness, hopelessness, and a lack of interest in daily activities. The patient expresses worthlessness and dissatisfaction with her family relationships, contributing to her overall emotional distress (Karrouri et al., 2021). Sleep disturbances and mood instability further support this diagnosis, indicating a need for interventions to address these depressive symptoms.
Generalized Anxiety Disorder (GAD) – ICD-10: F41.1: GAD involves excessive, uncontrollable worry about various aspects of life, often accompanied by physical symptoms such as restlessness or fatigue. The patient exhibits chronic anxiety regarding her family’s perceptions and interpersonal conflicts, leading to frustration and irritability (Mishra & Varma, 2023). This ongoing anxiety can exacerbate her emotional responses and complicate her ability to manage impulsivity.
Reflections:
Given a similar case, I will prioritize providing individualized and effective care. This approach will involve engaging the patient actively and effectively in the treatment plan. The first strategy will be to provide opportunities for the patient to participate in her care. I will prioritize creating a collaborative alliance and ensure that the underlying issues and needs are adequately and effectively addressed. I will also incorporate standardized assessment tools to evaluate the underlying issues and needs and determine practical approaches to enhancing the desired outcomes. These tools will provide insight into the existing problems, the progress, and the need to redesign the client’s treatment plan.
Individuals need adequate support to manage their mental health issues and needs and cope with the underlying stressors associated with them. Therefore, in dealing with these issues, some key health determinants are the social support networks, support systems, and the family dynamics required for managing these needs. Limited social support can exacerbate feelings of isolation and distress, contributing to her impulsive behaviors. Addressing these social factors through community resources and family involvement in therapy can help create a more supportive environment for the patient, enhancing her overall well-being. Therefore, through adequate community and family engagement, the patient will understand and accept the condition and effectively engage in designing appropriate mechanisms to address the issue of interest. Impulse Control Disorder Comprehensive Psychiatric Evaluation SOAP note
In my practice as an advanced provider, one health promotion activity would be to organize support groups for clients with impulse control and mood disorders where they would be able to support each other and share information as well as knowledge on how to cope with the disorder. For rehabilitation, I would educate the patient on stress reduction strategies like mindfulness or relaxation that can assist the patient in dealing with emotions. The main ethical issues are the principle of confidentiality and the right to informed consent. On the other hand, the legal issues involve evaluating the potential of a given patient to harm himself or others and guarantee the use of proper measures and precautions. It is by addressing these factors that health disparities for individuals with mental illness and ensuring equal access to mental health services can vastly improve.
Case Formulation and Treatment Plan:
The chosen treatment modality for P.M. is Cognitive Behavioral Therapy (CBT), which is aimed at addressing the decompensated negative thinking and maladaptive impulsive behaviors that were previously identified in her clinical presentation.CBT techniques focus on thoughts, feelings, and behaviors to enable the patient to change negative patterns into positive ones (Wheeler, 2020). It would be helpful for skills such as cognitive restructuring to address irrational thoughts and the use of coping skills for anger management to boost impulse control. The follow-up plan entails the patient continuing to have at least three consecutive weekly therapy sessions and assessing the improvement at each session. Some crucial aspects that need to be assessed in follow-up shall include her mood swings, sleeping habits, and any signs of aggressive behaviors (Boland et al., 2022). It is also vital that a referral to a psychiatrist for medication management might be suggested if a patient does not respond to psychotherapy. Family therapy sessions will also be recommended to understand the cause of the problem and how communication within the family can be enhanced.
I confirm that the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
Boland, R. J., Verduin, M. L., & Ruiz, P. (2022). Kaplan & sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Karrouri, R., Hammani, Z., Benjelloun, R., & Otheman, Y. (2021). Major depressive disorder: Validated treatments and future challenges. World Journal of Clinical Cases, 9(31), 9350–9367. https://doi.org/10.12998/wjcc.v9.i31.9350
Mishra, A., & Varma, A. (2023). A comprehensive review of the generalized anxiety disorder. Cureus, 15(9). https://doi.org/10.7759/cureus.46115
Scott, K. M., de Vries, Y. A., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Bromet, E. J., Bunting, B., Caldas-de-Almeida, J. M., Cía, A., Florescu, S., Gureje, O., Hu, C-Y., Karam, E. G., Karam, A., Kawakami, N., Kessler, R. C., Lee, S., McGrath, J., Oladeji, B., & Posada-Villa, J. (2020). Intermittent explosive disorder subtypes in the general population: association with comorbidity, impairment and suicidality. Epidemiology and Psychiatric Sciences, 29(138). https://doi.org/10.1017/S2045796020000517
Wheeler, K. (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing Company. Impulse Control Disorder Comprehensive Psychiatric Evaluation SOAP note
PRAC-6645-34 WEEK 7 ASSIGNMENT TWO PART 1&2 INSTRUCTIONS
TOPIC: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation, Part 1
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. Comprehensive psychiatric evaluation notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined at your practicum site, using the Comprehensive Psychiatric Evaluation Note Template provided. You will then use this note to develop and record a case presentation for this patient.
TO PREPARE:
- Review this week’s Learning Resources (BELOW) and consider the insights they provide about impulse-control and conduct disorders (BELOW).
- Select a patient for whom you conducted psychotherapy for an impulse control or conduct disorder during the last 6 weeks. Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide. All psychiatric evaluation notes must be signed by your Preceptor. When you submit your note, you should include the complete comprehensive evaluation note as a Word document and pdf/images of the completed assignment signed by your Preceptor. You must submit your note using Turnitin.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Grading Policy. - Then, based on your evaluation of this patient, develop a video presentation of the case. Plan your presentation using the Assignment rubric and rehearse what you plan to say. Be sure to review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
- Include at least five scholarly resources to support your assessment and diagnostic reasoning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
LEARNING RESOURCES:
- Classroom ProductionsLinks to an external site.. (Producer). (2016). Impulse and conduct disorders[Video]. Walden University.
- Professor Hartung. (2020). Multisystemic therapy (MST) for at-risk youth and juveniles informational webinarLinks to an external site.[Video]. YouTube. https://www.youtube.com/watch?v=yHbTEWCDlpE
Impulse Control Disorder Comprehensive Psychiatric Evaluation SOAP note instructions
THE PATIENT WE ARE WRITING ABOUT
The patient is a 47-year-old female who presents for a follow-up of impulse control, mood, and mood disorders. The patient’s brother complains that the patient is telling lies and when she is reproached for that, she becomes very angry and violent. She barely sleeps through the night. The patient acknowledges thoughts of self-harm or harming others when they are annoyed. She feels her family hates her, so she uses her aggressive behaviors to defend herself. Family Psychotherapy and CBT sessions were scheduled.
PLEASE, MAK E UP A STORY ON PATIENTS MOSTLY ON IMPULSE CONTROL DISORDER
THE ASSIGNMENT:
- Present the full complex case study. Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
- Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
- Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
- Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking. Impulse Control Disorder Comprehensive Psychiatric Evaluation SOAP note
PRAC_6645_Week7_Assignment2_PT2_Rubric
| PRAC_6645_Week7_Assignment2_PT2_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeReflections on this case. |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeComprehensive Psychiatric Evaluation documentation |
|
20 pts | ||||
| Total Points: 25 Impulse Control Disorder Comprehensive Psychiatric Evaluation SOAP note | ||||||
