NRNP 6665 Assignment 2: Focused SOAP Note And Patient Case Presentation

NRNP 6665 Assignment 2: Focused SOAP Note And Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP 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 during the last three weeks, using the Focused SOAP 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 and consider the insights they provide. Also, review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video. Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks. Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.

Please Note: All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted. When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor. You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy. Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record it. Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning. Ensure that you have the appropriate lighting and equipment to record the presentation.

The Assignment Record yourself presenting the complex case study for your clinical patient. In your presentation:

  • Dress professionally in a lab coat and present yourself in a professional manner.
  • Display your photo ID at the start of the video when you introduce yourself.
  • Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
  • Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
  • Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:

Subjective:What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is 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 their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

Plan:What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also, be sure to include at least one health promotion activity and one patient education strategy.

Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be.

PRAC 6665 Assignment 2 WEEK 3 Sample Solution

PRAC 6665 Assignment 2 WEEK 3: Comprehensive Psychiatric Evaluation and Patient Case Presentation Subjective: CC (chief complaint): “I have been experiencing suicidal thoughts for the last three weeks.”

HPI: A.A. is a 35-year-old male that came to the clinic today with complaints of suicidal thoughts for the last three weeks. The client reported a series of events leading to the symptoms. They included having a depressed mood almost all day and feeling hopeless. He also reported feelings of lack of energy, changes in appetite, and being socially isolated. He was worried that his interest in pleasure had declined significantly. A.A. also reported experiencing insomnia for the last two months and finding it hard to concentrate on things. He denied any suicidal plan or attempt. The symptoms could not be attributed to substance abuse, medication, or medical condition. The symptoms had affected his ability to engage in his social and occupational roles.

Substance Current Use: The client does not have a history of drug and substance abuse.

Medical History: No history of chronic illnesses or admission.

  • Current Medications: None
  • Allergies: Allergic to latex
  • Reproductive Hx: Married, has two children. He does not have a history of sexually transmitted infections or infertility. He does not have a history of increased urinary urgency and frequency.

ROS: GENERAL:  There is no evident weight loss, fever, chills, weakness, or fatigue. HEENT:  Eyes:  The patient denies visual loss, blurred vision, double vision, or yellow sclera. Ears, Nose, Throat:  The patient denies hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN:  The client denies rash or itching. CARDIOVASCULAR:  The client denies chest pain, chest pressure, or chest discomfort. No palpitations or edema. RESPIRATORY:  The client denies shortness of breath, cough, or sputum. GASTROINTESTINAL: The patient denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. GENITOURINARY: The patient denies burning on urination and has a history of sexually transmitted infections NEUROLOGICAL:  The patient denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL:  The client denies muscle or joint pain, joint rigidity, tenders, and difficulty in movement. He also denies fractures. HEMATOLOGIC:  The patient denies anemia, bleeding, or bruising. LYMPHATICS:  The patient denies enlarged nodes. No history of splenectomy. PSYCHIATRIC:  The patient denies any history of depression or anxiety. ENDOCRINOLOGIC:  The patient denies sweating, cold, or heat intolerance reports. No polyuria or polydipsia. ALLERGIES:  The patient is allergic to latex.

Objective: Diagnostic results: Some diagnostic investigations were ordered to determine the cause of the client’s problem accurately. Laboratory investigations, including complete blood count and thyroid function tests, were performed. Complete blood work aimed at determining any other conditions contributing to the worsening of the client’s symptoms. Thyroid function tests were performed to rule out thyroid disorders such as hyperthyroidism, which may produce symptoms similar to depression. Radiological investigations, including an MRI scan, were ordered to rule out pathologies such as brain tumors, which may contribute to the client’s symptoms (Alshawwa et al., 2019). The results were unremarkable, leading to a potential diagnosis of a mental health problem.

Assessment: Mental Status Examination: The client appeared dressed appropriately for the occasion. His orientation to self, others, time, and events were intact. His speech had a normal rate, speed, and volume. He maintained normal eye contact during the assessment. The self-reported mood of the client was depressed. He denied illusions, delusions, and hallucinations. He reported suicidal thoughts without plans or intent. The thought process was future-oriented.

Diagnostic Impression: Major Depression: Major depression is the primary diagnosis for the client. He presents with symptoms that align with depression, as stated in DSM-5. According to DSM-5, patients suffering from depression present with complaints that include depressed mood for most days, almost every day, diminished interest and pleasure, social isolation, and feelings of guilt. They also experience suicidal thoughts, attempts, or plans alongside having trouble making decisions. Patients also report increased irritability, sleeping patterns, and appetite changes (Kraus et al., 2019; Pradier et al., 2021). A.A. has most of the above symptoms, making depression the primary diagnosis.

Insomnia: The secondary differential diagnosis that should be considered for the client is insomnia. According to DSM-5, patients with insomnia report a decline in the quality and quantity of sleep. Poor sleep quality alters their normal routines and their ability to undertake their social, academic, and occupational roles (Albrecht et al., 2019). Unlike A.A., patients with insomnia do not experience depressed moods, lack of interest and pleasure, and suicidal thoughts.

Bipolar Disorder: The third secondary diagnosis that may be considered for the client is bipolar disorder. Patients with bipolar disorder experience cycles of mania and hypomania. The symptoms of elevated mood alternate with those of depressed mood (Perrotta, 2019). A.A. did not report such cycling in mood experiences, ruling out bipolar disorder as a possibility in his case.

Reflections:I believe that I did my best in examining this client. I utilized professional knowledge and skills in obtaining accurate data that led to the diagnosis. I also utilized evidence-based data to make informed decisions about the potential mental health problem of the client. I also incorporated collaboration in patients’ assessment and development of diagnosis and the plan of care. I would use the Patient Health Questionnaire-9 (PHQ-9) to determine the severity of depressive symptoms should I have the opportunity to assess the patient again. The assessment data will guide the determination of the appropriate dosing for the client’s medications.

Case Formulation and Treatment Plan: A.A. has been diagnosed with major depression. He has been initiated on PO Zoloft 25 mg daily for the next month. He has also been enrolled in group psychotherapy sessions. He has been scheduled for a follow-up visit after four weeks to determine his response to treatment.

References Albrecht, J. S., Wickwire, E. M., Vadlamani, A., Scharf, S. M., & Tom, S. E. (2019). Trends in Insomnia Diagnosis and Treatment Among Medicare Beneficiaries, 2006–2013. The American Journal of Geriatric Psychiatry, 27(3), 301–309. https://doi.org/10.1016/j.jagp.2018.10.017 Alshawwa, I. A., Elkahlout, M., El-Mashharawi, H. Q., & Abu-Naser, S. S. (2019). An Expert System for Depression Diagnosis. aKraus, C., Kadriu, B., Lanzenberger, R., Zarate Jr., C. A., & Kasper, S. (2019). Prognosis and improved outcomes in major depression: A review. Translational Psychiatry, 9(1), 1–17. https://doi.org/10.1038/s41398-019-0460-3 Perrotta, G. (2019). Bipolar disorder: Definition, differential diagnosis, clinical contexts, and therapeutic approaches. J Neuroscience and Neurological Surgery, 5. Pradier, M. F., Hughes, M. C., McCoy, T. H., Barroilhet, S. A., Doshi-Velez, F., & Perlis, R. H. (2021). Predicting change in diagnosis from major depression to bipolar disorder after antidepressant initiation. Neuropsychopharmacology, 46(2), 455–461. https://doi.org/10.1038/s41386-020-00838-x

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  • Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

  • Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

  • APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

  • Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

  • LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

  • Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

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