NRNP 6665 Assignment 2: Focused SOAP Note and Patient Case Presentation Paper

NRNP 6665 Assignment 2: Focused SOAP Note and Patient Case Presentation Paper

NRNP 6665 Assignment 2: Focused SOAP Note and Patient Case Presentation Paper

Subjective:

CC (chief complaint): “I feel sad most of the time, nothing interests me anymore.”

 

HPI:

K.L is a 48-year-old Hispanic female who presented to the psychiatric clinic with reports of feeling sad most of the time and losing interest in activities that previously brought pleasure. She reported that she started experiencing a change in mood nine weeks ago after she was laid off from her hotelier job. The client was laid off following a reduced clientele in the restaurant she worked in, and the management decided to lay off some employees to reduce the wage burden. Since then, she has lost interest in her hobbies and feels fatigued most of the time, which has limited her from attending to chores in her home. K.L reports that she feels lazy most of the time with low energy levels. Besides, she reports having sleeping difficulties and having a hard time getting to sleep with frequent night awakening. She reports that her appetite has increased over the past weeks resulting in gaining some pounds. She denies having suicidal thoughts or plans.

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Past Psychiatric History: No history of psychiatric diagnoses.

Past medication trials: None

 

Substance Current Use:

Denies tobacco or illicit drug use. Reports that her alcohol intake has increased to 3-4 glasses of whiskey about four days a week.

Medical History: Diagnosis:

 

Anemia at 40 years old; had four blood transfusions.

Current Medications: Vitamin B12 supplements.

Allergies: No drug or food allergies.

Reproductive Hx: Para 2+1. Positive history of recurrent VVC infections.

ROS:

• GENERAL: Positive for fatigue, low energy levels, and weight gain. Denies fever, chills, or malaise.
• HEENT: Denies visual changes, hearing loss, rhinorrhea, or sore throat.
• SKIN: Denies skin discolorations, itching, or bruises.
• CARDIOVASCULAR: Denies palpitations, chest pain, or SOB.
• RESPIRATORY: no complaints –Denies cough, chest pain, dyspnea, or sputum.
• GASTROINTESTINAL: Increased appetite. Denies nausea/vomiting, abdominal pain, or bowel alterations.
• GENITOURINARY: Denies pelvic pain or urinary symptoms.
• NEUROLOGICAL: Positive for fatigue. Denies headache, loss of consciousness, or tingling sensations.
• MUSCULOSKELETAL: No limitations in movement.
• HEMATOLOGIC: History of anemia and blood transfusion. No bruises or bleeding.
• LYMPHATICS: Denies lymph node enlargement.
• ENDOCRINOLOGIC: Denies heat/cold intolerance, polyuria, polydipsia, or polyphagia.

Objective:

Vital signs: B/P – 122/78, Pulse – 92, Resp -18, Temp – 98.6

Weight- 185 pounds; Height-5’4 BMI: 31.8

Diagnostic results:

No diagnostic tests ordered.

Assessment:

Mental Status Examination:

Hispanic female client, alert, and in no distress. The client was well-groomed and appropriately dressed. Her speech is slow and often stutters, but her tone is normal. The self-reported mood is sad, and the affect is blunted. She exhibits a linear, goal-directed, and coherent thought process. No hallucinations, delusions, obsessive thoughts, phobias, or suicidal thoughts/ideations were noted. She is oriented to person, place, and time. The client demonstrates good judgment and abstract thought, and her short- and long-term memory is intact. Insight is present.

Diagnostic Impression:

 

Differential Diagnoses

Major Depressive Disorder (MDD)

MDD manifests with a depressed/sad mood, reduced interest/pleasure, or both (Giannelli, 2020). MDD was the primary diagnosis based on the patient’s symptoms that met the DSM-V diagnostic criteria for MDD. Symptoms consistent with the diagnosis of MDD include sad mood, lack of interest, fatigue, low energy levels, appetite changes (increased appetite), weight gain, and sleeping difficulties (APA, 2013).

Insomnia

Insomnia is characterized by difficulty falling or staying asleep, early awakening, or a feeling of unrefreshing sleep (Krystal et al., 2019). Insomnia was a differential diagnosis based on the client’s complaint of experiencing sleeping difficulties, difficulty falling asleep, and frequent night awakening.

Adjustment Disorder

Adjustment Disorder manifests with behavioral or emotional symptoms related to a specific stressor. It presents with a depressed mood, anxiety, or misconduct (Zelviene & Kazlauskas, 2018). Adjustment Disorder is a differential diagnosis based on the patient’s history of having a sad mood after losing her job.

Plan

 

Pharmacological Therapy:

• Initiate Zoloft 50 mg PO once per day to alleviate depressive symptoms (Gartlehner et al., 2017).

Psychotherapy

• Cognitive-behavioral therapy.

Follow-up

The client will be followed-up after four weeks to evaluate his response to treatment.

Reflections:

If I were to conduct the session again, I would use the Patient Health Questionnaire-9 to determine the severity of depression. The results from the screening tool would guide in identifying the treatment approach for the patient. Besides, I would assess the patient for anxiety symptoms since Generalized Anxiety Disorder is a common comorbid of depression (Giannelli, 2020). The next interventions for this patient in the follow-up would be to assess the severity of depression symptoms and compare them with the previous assessment to establish progress with treatment. In addition, I would inquire from the patient on the presence of side effects from the medication (Gartlehner et al., 2017). I would also assess the degree of compliance with medication and psychotherapy and identify any issues affecting compliance.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Washington, DC: Author.

Gartlehner, G., Wagner, G., Matyas, N., Titscher, V., Greimel, J., Lux, L., … & Lohr, K. N. (2017). Pharmacological and non-pharmacological treatments for major depressive disorder: a review of systematic reviews. BMJ Open, 7(6), e014912. http://dx.doi.org/10.1136/bmjopen-2016-014912

Giannelli, F. R. (2020). Major depressive disorder. Journal of the American Academy of PAs, 33(4), 19-20. https://doi.org/10.1097/01.JAA.0000657208.70820.ab

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry: official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674

Zelviene, P., & Kazlauskas, E. (2018). Adjustment disorder: current perspectives. Neuropsychiatric disease and treatment, 14, 375–381. https://doi.org/10.2147/NDT.S121072

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Assignment 2: Focused SOAP Note and Patient Case Presentation

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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. 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 4 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 the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video

Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
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.
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 with 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 patient 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 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. 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 over? 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.
By Day 7 of Week 7
Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned PDF/images of each page that is initialed and signed by your Preceptor.

Submission and Grading Information
To submit your completed Assignment for review and grading, do the following: