NRNP 6665 Week 7 Assignment 2: Focused SOAP Note and Patient Case Presentation Paper

NRNP 6665 Week 7 Assignment 2: Focused SOAP Note and Patient Case Presentation Paper

NRNP 6665 Week 7 Assignment 2: Focused SOAP Note and Patient Case Presentation Paper

 

Subjective:

CC (chief complaint): “Psychiatric evaluation.”

HPI: P.L is a 54-year-old female patient who was accompanied by her sister to the psychiatric clinic as a result of strange behaviors. Her sister claims that the patient has been hearing sounds of people watching her across the window. She also reports that people on television are talking to her. She is very cautious, and if even afraid to eat as she believes that people on the television will pop out of the screen and poison her food. Additional symptoms include nightmares which affect her sleep. She denies suicidal ideation or potential harm to herself or others.

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Past Psychiatric History:

• General Statement: Hospitalized at the age of 20 years due to psychiatric disorder. She has been on and off antipsychotics.
• Caregivers (if applicable): She stays with her mother and sister.
• Hospitalizations: Reports a history of hospitalization at the age of 20 years.
• Medication trials: The patient was previously on Thorazine and Haldol, which she disliked how they made her feel. Seroquel was then introduced, which was effective, but the patient was inconsistent with taking the drug.
• Psychotherapy or Previous Psychiatric Diagnosis: None specified.

Substance Current Use: Reports smoking tobacco, approximately 3 packs every day. She also confirms taking alcohol. Denies taking marijuana or any other drug of abuse.

Family Psychiatric/Substance Use History: Mother with a history of anxiety disorder, while the father with a history of paranoid schizophrenia, Father was diagnosed with paranoid schizophrenia.

Psychosocial History: The patient lies together with her sister and mother. She is unable to work as a result of her mental condition, which affected her highest level of education being the 10^th grade.

 

Medical History: Currently managing diabetes. She also confirms having a fatty liver.

 

• Current Medications: Metformin 500mg twice daily.
• Allergies: No reported allergies

• Reproductive Hx: The patient denies ever being married. She confirms menopause at age of 45 years. No history of reproductive complications.

ROS:

• GENERAL: No fever, general body weakness, changes in body weight, fatigue, nausea, or vomiting.
• HEENT: Head: No headache or trauma. Eyes: No tearing, discharge, blurred vision, or redness. Ears: No discharge, tinnitus, or itchiness. Nose: No congestions or running nose. Throat: No sore throat, tonsillitis, or swallowing difficulties.
• SKIN: Intact with no rashes, hives, eczema, or itchiness.
• CARDIOVASCULAR: No palpitations, dyspnea, edema, cyanosis, or chest pressure.
• RESPIRATORY: No shortness of breath, wheezing, coughing, chest congestion, or sneezing.
• GASTROINTESTINAL: No changes in bowel movement, nausea, vomiting, diarrhea, constipation, abdominal tenderness, or hernia.
• GENITOURINARY: No dysuria, nocturia, discharge, urgency, or painful urination.
• NEUROLOGICAL: NO headache, loss of consciousness, or vision changes.
• MUSCULOSKELETAL: Full range of movement of joints with no pain, or inflammation.
• HEMATOLOGIC: No bleeding problems or prolonged healing of wounds.
• LYMPHATICS: No lymphedema
• ENDOCRINOLOGIC: No excessive thirst, polyuria, or polydipsia.

Objective:

Diagnostic results: For a general assessment of the patient’s health, routine blood works like WBC, RBC and CBC were ordered. A drug test of the urine and blood was also ordered to assess for substance use disorders. Organ function tests such as LFTs and RFTs were also ordered to assess the effects of the psychotropic agents on the patient’s liver and renal function. A CT scan of the head and X-Ray are also necessary to rule out physical trauma as the reason behind the patient’s condition. Additional diagnostic tests include Calgary Depression Scale for Schizophrenia, PANSS, Clinical Global Impression-Schizophrenia (CGI-SCH), SAPS test, Rorschach (inkblot) test, and SANS test (Lewine & Hart, 2020).

Assessment:

Mental Status Examination: The patient walks into the room, in age-appropriate and clean clothes. She seems quite confused and avoids eye contact. However, her orientation in person, time, and place are intact. She displays poor judgment and odd beliefs like her life is in danger. She is unable to maintain the same topic during the interview. Her short-term memory is quite shoddy, but her long-term memory is intact. She displays a flat affect. Her thought process is inconsistent, as she will give different answers to the same question. She displays signs of depression, anxiety, hallucination, and delirium. She denies suicidal ideation or potential harm to herself or others.

Diagnostic Impression:

1. Schizophrenia Spectrum and Other Psychotic Disorders: Schizophrenic patients tend to display characteristics that suggest that they have lost contact with reality. Common symptoms include abnormal behaviors, visual or auditory hallucination, delusion, and disorganized thought processes. The DSM-V diagnostic criteria for this disorder requires the patient to display at least one symptom, from each of the two groups of symptoms (Addington et al., 2017). The first group of symptoms entails disorganized thought processes and speech, hallucination, and delirium, while the second group involves catatonic symptoms such as stupor, mutism, catalepsy, or negativism. The patient displayed both positive and negative symptoms which qualify for this diagnosis.
2. Bipolar I Disorder with psychotic features: Patients with this disorder tend to have manic episodes, which are associated with psychotic features such as delusion and hallucination. The DSM-V diagnostic criteria require patients to present with at least 3 of the following manic symptoms such as inflated self-esteem, reduced sleep, easily distracted, racing thoughts, irritability, and increased psychomotor agitation (Tasic et al., 2019). The patient must also present with at least one psychotic feature such as hallucination, or delusion to qualify for this diagnosis. The patient displayed psychotic symptoms, with no manic episodes, which disqualifies this diagnosis.
3. Delusional Disorder: In most cases, delusion is a symptom of other psychotic conditions. However, according to DSM-V, patients who display delusion only, and no other psychotic symptoms, for at least one month, qualifies for this diagnosis (Lewine, & Hart, 2020). However, the present patient displayed both delusion and hallucination among other symptoms. As such, she cannot qualify for this diagnosis.

Case Formulation and Treatment Plan:

Pharmacotherapy: Initiate 300mg of quetiapine (Rx) Extended-release on day one. Titrate the dose upwards by 25-50 mg per day to an optimal maintenance dose of between 400 to 800 mg once daily while observing patient outcome (Remington et al., 2017). This drug is effective in the management of schizoaffective symptoms and had already displayed great tolerance and adherence with the patient. The extended-release formulation will also help reduce the frequency of administration, hence promoting compliance.

Psychotherapy: Cognitive behavior therapy (CBT) is recommended among patients with schizophrenia to help promote appropriate behavior and positive thinking (Stijažiü et al., 2017).

Alternative therapy: The patient can also engage in Assertive community treatment (ACT), coordinated specialty care (CSC), self-help groups, or social skills training (Lewine, & Hart, 2020).

Health Promotion: Take part in physical exercise and consume a healthy diet to promote both physical and mental health (Stijažiü et al., 2017).

Patient Education: The patient must be educated on the importance of the consistency of taking medication as prescribed to promote treatment outcomes (Stijažiü et al., 2017).

Follow-up: The patient must report back to the clinic after 4 weeks for further evaluation of the treatment outcome so that necessary changes can be made to the treatment plan.

Reflections: The patient information provided is limited in making the required changes in the patient medication based on the severity of her condition. Both the subjective and objective portions of patient history suggest a diagnosis of schizophrenia. However, concerning her previous treatment approaches, some information is missing concerning the drug-specific side effects encountered, and the level of effectiveness of the psychotropic agents used. As such, it is necessary to talk to the patient informant more concerning her previous treatment to make sure that the current treatment plan does not display similar results. Consequently, the PMHNP must promote the health and well-being of the patient and prevent harm. As such, the next intervention will entail using both pharmacological agents which displayed great effectiveness with no harm to the patient, and psychotherapy, to promote patient’s compliance and treatment outcome (Remington et al., 2017).

References

Addington, D., Abidi, S., Garcia-Ortega, I., Honer, W. G., & Ismail, Z. (2017). Canadian guidelines for the assessment and diagnosis of patients with schizophrenia spectrum and other psychotic disorders. The Canadian Journal of Psychiatry, 62(9), 594-603. https://doi.org/10.1177/0706743717719899

Lewine, R., & Hart, M. (2020). Schizophrenia spectrum and other psychotic disorders. In Handbook of Clinical Neurology (Vol. 175, pp. 315-333). Elsevier. https://doi.org/10.1016/b978-0-444-64123-6.00022-9

Remington, G., Addington, D., Honer, W., Ismail, Z., Raedler, T., & Teehan, M. (2017). Guidelines for the pharmacotherapy of schizophrenia in adults. The Canadian Journal of Psychiatry, 62(9), 604-616. https://doi.org/10.1177/0706743717720448

Stijažiü, D., Jendrižko, T., & Biožina, S. M. (2017). Guidelines for individual and group psychodynamic psychotherapy for the treatment of persons diagnosed with psychosis and/or schizophrenia. Psychiatria Danubina, 29(3), 432-440. PMID: 28953804

Tasic, L., Larcerda, A. L., Pontes, J. G., da Costa, T. B., Nani, J. V., Martins, L. G., … & Hayashi, M. A. F. (2019). Peripheral biomarkers allow differential diagnosis between schizophrenia and bipolar disorder. Journal of psychiatric research, 119, 67-75. https://doi.org/10.1016/j.jpsychires.2019.09.009

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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.