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Create documentation in the Focused SOAP Note Template about the patient in the case study.
In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS
Points:
Points Range:
14 (14%) – 15 (15%)
The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
Feedback:
Points:
Points Range:
12 (12%) – 13 (13%)
The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.
Feedback:
Points:
Points Range:
11 (11%) – 11 (11%)
The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies.
Feedback:
Points:
Points Range:
0 (0%) – 10 (10%)
The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.
Feedback:
In the Objective section, provide:
• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Week 4
Introduction
Resources
Assignment
Looking Ahead
My Progress Tracker
NRNP 6665: PMHNP Care Across the Lifespan I | Week 4
Introduction
Resources
Assignment
Looking Ahead
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Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Week 4
Introduction
Resources
Assignment
Looking Ahead
My Progress Tracker
NRNP 6665: PMHNP Care Across the Lifespan I | Week 4
Introduction
Resources
Assignment
Looking Ahead
☰Menu
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NRNP 6665: PMHNP Care Across the Lifespan I
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Week 4: Mood Disorders in Adults
I am finally doing everything right. I stayed up all night studying for my final exams and even managed to clean out my closet and order a whole new bedroom from the internet. I know I will ace all my exams. Nothing can go wrong like they did a few months ago. I was so low and was sleeping all the time. I did not think I would ever be happy again, but now I know I can do anything.
—Jessica, age 22
Patients presenting with mood disorders may find that their moods impact their ability to function or that their moods are not consistent with their circumstances. Bipolar and related disorders are one category of mood disorders. They affect nearly 3% of the U.S. population each year (Depression and Bipolar Support Alliance, n.d.). Although being relatively rare in terms of lifetime prevalence, bipolar disorder is burdensome to the individual and health care system because of its early onset, severity, and chronic nature. The average age of onset is around 25 and it affects men and women equally.
The importance of evidence-based intervention for treatment in persons with mood disorders cannot be underestimated. Unstable moods can result in repeat chronic hospitalizations and profound life disruption. Mood disorders are a leading cause of disability worldwide and can contribute to suicide (World Health Organization, 2020). Practitioners should understand that developing a good rapport and relationship with the patient can make a significant difference in the course, symptom management, and stability of the patient.
This week, you will assess, diagnose, and dev
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template
AND
the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
· Chief complaint
· History of present illness (HPI)
· Past psychiatric history
· Medication trials and current medications
· Psychotherapy or previous psychiatric diagnosis
· Pertinent substance use, family psychiatric/substance use, social, and medical history
· Allergies
· ROS
Read rating descriptions to see the grading standards!
In the Objective section, provide:
· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
· Results of the mental status examination,
presented in paragraph form.
· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case
.
· Read rating descriptions to see the grading standards!
Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (
demonstrate critical thinking beyond confidentiality and consent for treatment
!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
· Current Medications:
· Allergies:
· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
References
© 2021 Walden University
Page 1 of 3
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint):
HPI:
Substance Current Use:
Medical History:
· Current Medications:
· Allergies:
· Reproductive Hx:
ROS:
· GENERAL:
· HEENT:
· SKIN:
· CARDIOVASCULAR:
· RESPIRATORY:
· GASTROINTESTINAL:
· GENITOURINARY:
· NEUROLOGICAL:
· MUSCULOSKELETAL:
· HEMATOLOGIC:
· LYMPHATICS:
· ENDOCRINOLOGIC:
Objective:
Diagnostic results:
Assessment:
Mental Status Examination:
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
References
© 2021 Walden University
Page 1 of 3
Case Study: Petunia Park
© 2020 Walden University 1
Case Study: Petunia Park
Program Transcript
[MUSIC PLAYING]
DR. MOORE: Hi. Good afternoon. My name is Dr. Moore. Am I understanding you’re
here for a mental health assessment today?
PETUNIA PARK: That’s right.
DR. MOORE: OK. So to make sure I have the right patient and the right chart, can you
tell me your name and your date of birth?
PETUNIA PARK: Yes. I’m Petunia Park. My birthday is July 1, 1995.
DR. MOORE: And can you tell me what today’s date is?
PETUNIA PARK: So it’s December 1.
DR. MOORE: Do you know the year?
PETUNIA PARK: 2020.
DR. MOORE: And what day of the week is this?
PETUNIA PARK: It’s Tuesday.
[CHUCKLING]
DR. MOORE: And do you know where we are today?
PETUNIA PARK: Yes I am here in the beautiful, sunny office at the clinic.
DR. MOORE: OK, great. Thank you. So can you tell me a little bit about why you’re here
today? What brings you here today?
PETUNIA PARK: Yes. So I have a history of taking medications and then stopping
them. I don’t think I need them. I really feel like the medication squashes who I am.
DR. MOORE: OK, OK. So I’m going to be able to help you with that. But to begin, I’m
going to ask you some questions about your family. I’m going to ask you some history-
type questions. I’m going to ask you some symptoms that you might be having. And all
of these questions are going to help me work with you on a treatment plan, OK? So I
would like to begin with, when was the first time that you ever had any mental health or
substance use treatment in your life?
Case Study: Petunia Park
© 2020 Walden University 2
PETUNIA PARK: OK. Well, when I was a teenager, my mom put me in the hospital after
I went four or five days without sleeping. I think I may have been hearing things at that
time. [CHUCKLES] I think they started me on some medication, but I’m not sure.
DR. MOORE: Oh, OK so you were hospitalized. How many times have you been
hospitalized for mental health?
PETUNIA PARK: Oh, I’ve been hospitalized about four times. The last time was this
past spring. No detox or residential rehabs, though.
DR. MOORE: OK, good. Were any of these hospitalizations due to any suicide
gestures?
PETUNIA PARK: One was in 2017. I overdosed on Benadryl, but I’ve not had those
thoughts since then.
DR. MOORE: Well, I’m very glad to hear that you’ve not had any of those thoughts
since then. And I’m glad that you turned out OK from that overdose. I’m glad that you’re
here today. Can you tell me a little bit about what you’ve been diagnosed with during
your past treatments?
PETUNIA PARK: Well, I think depression, and anxiety, had some even say maybe
bipolar.
DR. MOORE: OK, and what medications have you been tried on before for those
illnesses? And if you can remember, what was your reactions to those medications?
PETUNIA PARK: Oh, let’s see. Oh, I took Zoloft, and that made me feel really hig
WAL_NRNP6665_04_A_EN-CC.mp4
1
Assessing, Diagnosing, and Treating Adults With Mood Disorders
##########
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
############
June 28, 2021
2
Assessing, Diagnosing, and Treating Adults With Mood Disorders
CC (chief complaint): “I have a history of taking medications and then stopping them. I
feel like the medications squashes who I am.”
Subjective: P.P is a 36 year old Caucasian (appears to be) female presenting for a
psychiatric assessment for symptoms of depression. She reports the depressive symptoms occur
about 4 times a year where she doesn’t want to get out of bed, loses creative interest which leads
to feeling worthless, reports having no motivation or energy to do anything. She states these
depressive episodes usually come after having been awake for 4-5 days working on projects and
using a lot of creative energy (music, painting, writing). She states others have told her she is
depressed but she is not sure and thinks her depressive symptoms have more to do with feeling
exhausted after being awake for days at a time. She reports the energy highs during the days she
doesn’t sleep are her favorite experiences as she feels most creative and excited. Denies
excessive worrying or obsessive tendencies. She states she will hear voices sometimes after not
sleeping for days and the voices tell her she’s wonderful and creative. She reports lack of
appetite and not eating much at all when she’s in those creative high episodes of not sleeping but
will be hungry and eat “everything in sight” when she’s exhausted and depressed. Denies having
nightmares and reports averaging 5-6 hours of sleep per night. When she’s experiencing the
creative high she feels lucky if she gets 3 hours in a week. When she’s exhausted and depressed
she sleeps between 12-16 hours per day.
HPI: Patient reports her mental health symptoms include depression and some anxiety
and has been told by others she could be bipolar. Her symptoms began as a teenager and she first
received treatment when her mother had her hospitalized after she had not slept for 4 or 5 days
straight and experienced auditory hallucinations. She reports having been hospitalized a total of 4
3
times with her most recent being this past spring. She reports one of the hospitalizations was due
to suicide attempt in 2017 where she overdosed on Benadryl. The patient denies a history of
detox or residential treatment. States she has not had suicidal ideation or attempts since 2017.
Psychosocial History: Patient reports she was raised mostly by her mother. She denies
any legal history minus an incident she recalls where police picked her up for dancing in a
nightgown in a field with her guitar but believes her mother may have lied and made-up the
incident to get her to return to her boyfriend. Patient reports “having lots of sex” with different
people because it makes her feel good and high
1
Week 4: Mood Disorders in Adults
Jacey Duffy
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Dr. Ngyia
March 29, 2021
This study source was downloaded by 100000822789681 from CourseHero.com on 03-25-2022 17:58:04 GMT -05:00
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https://www.coursehero.com/file/96972563/WK4AssgnDuffyJdocx/
2
Assessing, Diagnosing, and Treating Adults with Mood Disorders
Mood disorders are a category of psychiatric illnesses that typically affect a
person’s psychological state of well-being (Sadock et al., 2015). Although mood
disorders can negatively impact an individual’s life, relationships, and employment, they
can be successfully treated with the proper use of psychotropic medications and
psychotherapy. The purpose of this assignment is to develop a SOAP note based on
the evaluation of the client in case study for this week’s assignment. A comprehensive
assessment will be provided, along with a diagnosis, and a designed treatment plan
based on best-evidence-based practice standards and clinical guidelines.
Focused SOAP Note
Subjective:
CC: The client presents today for a mental health assessment complaining of having a
history of taking medications, then stopping them, because she does not think she
needs them. She reports that the feels as if the medications “squashes” who she is
(Walden University, 2021).
HPI: Petunia Park is a 25-year-old white female who presents today for a mental health
assessment. The client reports that she has been admitted to the hospital four times for
mental health issues. The client reports that she was first hospitalized as a teenager by
her mother because she had gone 4-5 days without sleeping. In 2017, the client was
hospitalized for an attempted suicide when she overdosed on Benadryl, at which time
she reports hearing voices. The client reports that she was hospitalized after being
found by the cops dancing around in a field in her nightgown with her guitar. Although
she feels as if her mom made up this story to force her to go back to live with her
boyfriend.
The client reports that she has been diagnosed with depression, anxiety, and
bipolar disorder in the past. She has been prescribed Zoloft in the past and reports that
it made her feel really “high” and she couldn’t sleep due to racing thoughts. Risperdal
and Seroquel caused her to gain weight which she did not like. The medication Klonopin
she reports slowed her down some which she did not like either.
The client reports that four to five times a year she has times where she does not
want to get out of bed, has no energy, no motivation to do anything, loss of interest in
things she enjoys, and feels worthless. The client also reports “creativity” where she
This study source was downloaded by 100000822789681 from CourseHero.com on 03-25-2022 17:58:04 GMT -05:00
https://www.coursehero.com/file/96972563/WK4As
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