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GNRS 534 / GNRS534 -BPD SOAP Answered Latest 2025/26., Study Guides, Projects, Research of Nursing

CC: Patient presents with complaints of recent self-harm, feelings of boredom, and frustration with current living situation HPI: Mr. Rice is a 37-year-old African American male who presented to the clinic for a wrist infection. He reported that injury occurred as a result of his impulsive act of breaking a window during a party at the fraternity he was living in. He reported dissatisfaction with his living arrangements at the fraternity, and being left out and lonely most of the time. Mr. Rice reported consuming alcohol during social events, and attributed that to his boredom, the self-centered fraternity brothers, and the lack of meaningful connections. Mr. Rice stated he has a history of self-harm, few suicide attempts such as the severe burns self-inflicted at the age of seventeen or eighteen. He stated that he needs more meaningful social interactions and intellectual engagement, which he feels he lacks in the fraternity setting. Mr.

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BPD
Criteria
Clinical Notes
Subjective
CC: Patient presents with complaints of recent self-harm, feelings of
boredom, and frustration with current living situation
HPI: Mr. Rice is a 37-year-old African American male who presented
to the clinic for a wrist infection. He reported that injury occurred as a
result of his impulsive act of breaking a window during a party at the
fraternity he was living in. He reported dissatisfaction with his living
arrangements at the fraternity, and being left out and lonely most of
the time. Mr. Rice reported consuming alcohol during social events,
and attributed that to his boredom, the self-centered fraternity
brothers, and the lack of meaningful connections. Mr. Rice stated he
has a history of self-harm, few suicide attempts such as the severe
burns self-inflicted at the age of seventeen or eighteen. He stated
that he needs more meaningful social interactions and intellectual
engagement, which he feels he lacks in the fraternity setting. Mr.
Rice reported he met a woman named Miss Murray at a bus stop
and felt a connection with her, and would like to move in with her for
companionship and stimulating conversations.
Past Psychiatric History:
General statement: reports that he has been under
psychiatric treatment prior to this evaluation, and previously
sought help for mental health concerns but without success.
Current Caregivers: none
Hospitalization history: Mr. Rice’s history of seeking
psychiatric care, previous severe medical hospitalizations,
and mentions of self-harm and suicidal ideation indicate a
complex mental health background that may include past
psychiatric hospitalizations.
Medication history: He has no prior history of psychiatric
medications.
Psychotherapy/Previous Pychiatric Diagnosis: He had seen
psychiatrists in different cities, but he expressed
dissatisfaction with the psychiatric care he received in the
past because it did not improved his mental health. He
moved to his current area in search of a decent psychiatrist
because of its reputation as a supportive mental health
community, but he is not currently in contact with any mental
health specialists. Mr. Rice stated that he attempted suicide
on multiple occasions, which may warrant hospitalization if
he were to present with severe suicidal ideation or behaviors
Include chief
complaint, subjective
information from the
patient, names and
relations of others
present in the
interview, and basic
demographic
information of the
patient. HPI, Past
Medical and
Psychiatric History,
Social History.
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BPD

Criteria Clinical Notes Subjective CC : Patient presents with complaints of recent self-harm, feelings of boredom, and frustration with current living situation HPI : Mr. Rice is a 37 - year-old African American male who presented to the clinic for a wrist infection. He reported that injury occurred as a result of his impulsive act of breaking a window during a party at the fraternity he was living in. He reported dissatisfaction with his living arrangements at the fraternity, and being left out and lonely most of the time. Mr. Rice reported consuming alcohol during social events, and attributed that to his boredom, the self-centered fraternity brothers, and the lack of meaningful connections. Mr. Rice stated he has a history of self-harm, few suicide attempts such as the severe burns self-inflicted at the age of seventeen or eighteen. He stated that he needs more meaningful social interactions and intellectual engagement, which he feels he lacks in the fraternity setting. Mr. Rice reported he met a woman named Miss Murray at a bus stop and felt a connection with her, and would like to move in with her for companionship and stimulating conversations. Past Psychiatric History :

  • General statement: reports that he has been under psychiatric treatment prior to this evaluation, and previously sought help for mental health concerns but without success.
  • Current Caregivers: none
  • Hospitalization history: Mr. Rice’s history of seeking psychiatric care, previous severe medical hospitalizations, and mentions of self-harm and suicidal ideation indicate a complex mental health background that may include past psychiatric hospitalizations.
  • Medication history: He has no prior history of psychiatric medications.
  • Psychotherapy/Previous Pychiatric Diagnosis: He had seen psychiatrists in different cities, but he expressed dissatisfaction with the psychiatric care he received in the past because it did not improved his mental health. He moved to his current area in search of a decent psychiatrist because of its reputation as a supportive mental health community, but he is not currently in contact with any mental health specialists. Mr. Rice stated that he attempted suicide on multiple occasions, which may warrant hospitalization if he were to present with severe suicidal ideation or behaviors Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.

in the future. Substance Current use : Reports ocassional alcohol use but denies cigarette smoking, or other illicit drugs. Family Pyschiatric history : Mr. Rice does not mention any psychiatric history of his parents or other family members during the interview. This lack of information makes it difficult to assess whether there is a genetic or familial predisposition to mental health conditions. Social history : Mr. Rice indicates that during the first three years of his life, he was hospitalized due to a congenital heart condition, and his family lived a hundred miles away from the hospital. This suggests that while he had parents their involvement during that time may have been limited due to the distance and circumstances. He has a history of feelings of being an outsider, which he also experienced growing up and attending school. Recently, Mr. Rice lived in a fraternity, where he described himself as an "honorary member." He felt disconnected from other members and found the environment unfulfilling and boring. He had some work experience, mentioning a short stint as a short-order cook that he left due to physical pain from scar tissue on his chest. Past Medical history :. He has a history of hospitalizations and complications during early childhood due to congenital heart conditions, which has contributed to his feelings of isolation throughout his life. Past Surgical history :. Burn Injury : He mentioned being burned on his chest when he was seventeen or eighteen years old due to pouring gasoline and then lighting it. This incident resulted in significant burns that required hospitalization for almost a year. Congenital Heart Condition : Mr. Rice also referenced having a congenital heart condition that involved complications requiring surgery during his early childhood. He spent the first three years of his life in the hospital due to this condition and the associated complications, suggesting multiple medical interventions, including surgeries. Medications : Mr. Rice noted a lack of effective treatment from past psychiatrists, which may have included medications, but he did not detail any specific psychiatric medications. Mr. Rice was prescribed Amoxicillin for the wrist infection. Allergies : No food allergies. No seasonal allergies. Drugs:Penicillin (reaction: rash) Spiritual history : none Primary Care Physician : Patient does not see a physician regularly.

ROS :

General : Mr. Rice denies fever, generalized weakness, or chills.

ruminations about the past, self-harm, and a longing for connection. No current suicidal ideation was noted during the discussion. He is alert and oriented x 4, with no memory deficits. Denies hallucinations or delusions but but his ability to maintain a coherent train of thought appears impaired during emotionally charged discussions. Mr. Rice demonstrated limited insight into his condition, as evidenced by impulsive behaviors (e.g., breaking a window resulting in injury) and the self-destructive thoughts surrounding his living situation and social interactions. Assessment Borderline personality disorder (F60.3)

  • According to DSM-5, pervasive patterns of mood, self-image, and interpersonal connection instability are hallmarks of borderline personality disorder (BPD), a mental health illness. Individuals with BPD frequently have skewed views of both themselves and other people, which makes it challenging to keep up steady, wholesome relationships. People who have borderline personality disorder (BPD) struggle to control their emotions, exhibit impulsive behaviors, and have strong, quickly fluctuating emotions. Impulsivity, self-harming behaviors, and suicidality are examples of maladaptive behaviors that can be fueled by a fear of abandonment. Feelings of emptiness can be persistent for those with BPD. Mr. Rice appears moody, angry, and impulsive. He mentions few unstable or hasty relationships such as the fraternity brothers and Miss Murray. He feels abandoned by the fraternity brothers and as a result he ends up breaking a window and getting injured. He mentions being burned when he was seventeen or eighteen years old, resulting in severe burns that led to almost a year-long hospitalization. This event also implies the possibility of psychological trauma associated with the burn injury and its aftermath. He mentions the distance between the hospital and his family’s home. He has a history of feelings of being an outsider, which he also experienced growing up and attending school. According to DSM-5, individuals with BPD have an intense fear of abandonment and are intolerant to being alone, which may lead to suicidal ideation, or impulsive actions. Differential diagnosis: Adjustment disorder (F43.2). According to DSM-5, the diagnosing criteria is: the development of emotional or behavioral symtpms in response to an identifiable stressor occurring within 3 months of the onset of the stressor. The major stressor in Mr. Rice’s case is the perceived abandonment from the fraternity brothers. Adjustment Disorder is recognized in the Include your findings, diagnosis and differentials (DSM- 5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

DSM-5 as a response to stressors that leads to clinically significant emotional or behavioral symptoms and is categorized as a stressor- related disorder. He reports feelings of boredom, frustration, and dissatisfaction with his life, resulting in an impulsive behavior (breaking a window and cutting his wrist) and past suicide attempts indicates potential emotional or behavioral responses to the stressor. Major Depressive Disorder F60. DSM-5 Criteria for MDD includes 5 or more of the following symptoms: depressed mood, loss of interest or pleasure, weight loss/gain, sleep disturbances, psychomotor agitation/retardation, feelings of worthlessness or guilt, diminished concentration, or fatigue. Additionally, symptoms can include suicidal ideation. Plan Treatment /Plan The treatment plan for Mr. Rice includes:

  • Psychotherapy is the initial line of treatment for BPD. Patients with BPD respond better to BPD-tailored therapy than to standard care. Psychotherapy decreased the intensity of BPD symptoms, enhanced psychosocial functioning, and may lessen depression and self-harm in clinical trials.
  • Dialectical Behavior Theory : developing skills in emotion regulation, mindfulness, and interpersonal interaction is the goal of DBT, which tries to alter behavior and help the patient tolerate uncomfortable emotions. Individual therapy, group therapy, and weekly team consultations for the therapists are all combined in DBT.
  • DBT can be adapted to address co-occurring mental health issues, such as depression, substance use disorders, or PTSD.
  • Contrary to recommendations, up to 96% of BPD patients use at least one psychotropic medication, despite the lack of evidence supporting the effectiveness of pharmacotherapy for the disorder's fundamental symptoms (Chapman, 2024)
  • Only comorbid conditions such severe anxiety or depression, temporary psychotic symptoms, extreme agitation, or aggressive behavior should be treated with pharmacotherapy.
  • Mr. Rice expresses feelings of hopelessness, frustration with social isolation, and dissatisfaction with his past psychiatric care. These emotional distress signals may indicate underlying conditions such as MDD or anxiety, which may benefit from additional therapeutic approaches or Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.