Assignment 12: SOAP Note and Patient Case

Assignment 12: SOAP Note and Patient Case

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 for Assignment 12: SOAP Note and Patient Case

  • 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.

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.

Assignment 12: SOAP Note and Patient Case – 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 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 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.

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NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Example
CC (chief complaint): Depression and anxiety, challenges with body image, motivation, and social withdrawal.

HPI: Patient reports ongoing struggles with depression and anxiety, recently exacerbated by new job challenges and body image concerns. Initiated therapy and is exploring medication optimization, including genetic testing.

Past Psychiatric History:

  • General Statement: History of premenstrual dysphoric disorder, generalized anxiety disorder, OCD unspecified, binge eating disorder, major depressive disorder, recurrent episodes with anxious distress, and ADHD, attentive type.
  • Caregivers (if applicable): None.
  • Hospitalizations: Outpatient in 2011 at Rockford House in Delaware.
  • Medication trials: Past medications include Lexapro, Zoloft, Wellbutrin, Xanax, Adderall, Adderall XR, Propranolol, Silexan. Current medications include Prozac, Adzenys, Hydroxyzine, Wellbutrin XL, Dupixent, Wegovy.
  • Psychotherapy or Previous Psychiatric Diagnosis: Ongoing therapy sessions, previously diagnosed with aforementioned disorders.

Substance Current Use and History: Denies drug and alcohol abuse, except for social drinking.

Family Psychiatric/Substance Use History: Father with DM, HTN, hypothyroid; mother with HTN; sister on Lexapro with weight gain.

Psychosocial History: Lives alone. Enjoys activities like working out, gym, yoga, and beach visits. Denies tobacco use, no history of STDs.

Medical History:

  • Current Medications: Prozac 40mg, Adzenys 18.8mg, Hydroxyzine 10mg, Wellbutrin XL 150mg, Dupixent, Wegovy, fish oil, Vit D, Zinc with Vit C, MVI.
  • Allergies: Cecor, latex.
  • Reproductive Hx: Regular menstrual cycles without significant issues.

ROS:

  • GENERAL: No appetite or significant weight changes, generally alert.
  • HEENT: Normocephalic, no visual or auditory complaints.
  • SKIN: Clear, no rashes or lesions.
  • CARDIOVASCULAR: Denies chest pain, palpitations.
  • RESPIRATORY: Clear breath sounds, no dyspnea.
  • GASTROINTESTINAL: Normal bowel habits, no abdominal pain or discomfort.
  • GENITOURINARY: No urinary complaints or dysfunctions.
  • NEUROLOGICAL: No history of seizures, headaches, or syncope.
  • MUSCULOSKELETAL: Full range of motion, no joint pain or swelling.
  • HEMATOLOGIC: No history of anemia or bleeding disorders.
  • LYMPHATICS: No lymphadenopathy.
  • ENDOCRINOLOGIC: History of PCOS.

Physical exam:

  • General Appearance: Well-groomed, no acute distress.
  • Vital Signs: Within normal limits.
  • Neurological: Alert, oriented, cranial nerves intact.
  • Cardiovascular: Regular rhythm, no murmurs.
  • Respiratory: Clear to auscultation bilaterally.
  • Abdominal: Soft, non-tender, no organomegaly.
  • Musculoskeletal: Normal strength and tone, no deformities.

Diagnostic results:

  • Blood work pending.
  • Gene site testing being considered for medication optimization.

Assessment Mental Status Examination: Kempt appearance, alert, cooperative behavior, limited focus, intact memory, low mood, adequate sleep, calm gross motor activity, normal gait, no tremors, oriented, appropriate eye contact, normal rate of speech, congruent affect, logical thought process, no delusions, fair insight and judgment.

Differential Diagnoses:

  1. F33.1 Major Depressive Disorder, Recurrent Episode, with Anxious Distress: The patient’s ongoing struggles with depression, including feelings of low mood, lack of motivation, social withdrawal, and numbness, align with this diagnosis. The presence of anxiety symptoms alongside depression further supports the specification of “with anxious distress (Marx et al., 2023).
  2. F41.1 Generalized Anxiety Disorder: The patient’s experiences of anxiety, particularly in the context of new job challenges and body image concerns, suggest this disorder. Symptoms like worry and feeling on edge are characteristic of generalized anxiety disorder (Nilsson et al., 2019).
  3. F32.81 Premenstrual Dysphoric Disorder (PMDD): Considering the patient’s history of mood and anxiety symptoms potentially correlating with menstrual cycles, PMDD might be a relevant diagnosis. This condition involves more severe emotional and physical symptoms than typical premenstrual syndrome (PMS) (Carlini et al., 2020).
  4. F42.9 Obsessive-Compulsive Disorder, Unspecified: The patient’s prior diagnosis and potential ongoing symptoms of OCD, although not detailed in the current history, indicate that this diagnosis should be considered. OCD involves unwanted, persistent thoughts (obsessions) and/or repetitive behaviors (compulsions). (Stein et al., 2019)
  5. F90.0 Attention Deficit Hyperactivity Disorder, Inattentive Type: The patient’s history of ADHD and current challenges with focus and concentration suggest the continuing relevance of this diagnosis. Inattentive type ADHD is characterized by difficulties with attention, organization, and follow-through (Cortese, 2020).
  6. F50.81 Binge Eating Disorder: This diagnosis could be pertinent, given the patient’s history of binge eating disorder. Current symptoms need to be evaluated to confirm if this disorder is still active.

Reflections:

Reflecting on the learning experiences of this quarter, the comprehensive case study of a patient with complex psychiatric needs stands out as a pivotal element of my educational journey. This case has served as a practical application of theoretical knowledge, bridging the gap between textbook learning and real-world clinical scenarios. It emphasized the importance of a thorough understanding of various psychiatric conditions, including Major Depressive Disorder, Generalized Anxiety Disorder, and Attention Deficit Hyperactivity Disorder, among others.

The patient’s case was particularly enlightening in understanding the intricacies of psychiatric comorbidities. Dealing with multiple diagnoses within a single patient highlighted the necessity of a holistic approach in mental health care, where different disorders often interplay and impact one another. This aspect of the learning has deepened my appreciation for comprehensive patient assessments, considering not just the presenting symptoms but also the broader psychosocial context.

One of the most significant learnings from this quarter has been the importance of detailed patient history in forming an accurate diagnosis and effective treatment plan. The patient’s past experiences, responses to various medications, and personal lifestyle choices all played a crucial role in shaping her current mental health status. This reinforced the value of patient-centered care, where understanding and integrating the patient’s preferences, concerns, and unique life circumstances are as crucial as clinical expertise.

Additionally, this quarter has brought into focus the importance of psychotherapy in treating mental health conditions. The patient’s proactive approach to finding a suitable therapist and her engagement in therapy sessions underscored the role of psychotherapeutic interventions in conjunction with pharmacotherapy. The case also served as a reminder of the impact of life transitions and stressors on mental health. The patient’s challenges with body image and recent job change were stark examples of how external factors can exacerbate existing mental health conditions, emphasizing the need for adaptive and responsive treatment plans.

Moreover, working through the process of developing differential diagnoses for this patient was a rigorous exercise in critical thinking and clinical reasoning. It required a careful analysis of the patient’s symptoms, a deep understanding of how various conditions manifest, and an ability to discern the subtleties of different psychiatric disorders. Lastly, this experience highlighted the significance of multidisciplinary collaboration in mental health care. The patient’s situation, involving a primary care provider for her polycystic ovary syndrome and the potential coordination with genetic testing specialists, illustrated the interconnectedness of various health care domains in managing complex cases.

Assignment 12: SOAP Note and Patient Case References

Carlini, S. V., & Deligiannidis, K. M. (2020). Evidence-based treatment of premenstrual dysphoric disorder: A concise review. The Journal Of Clinical Psychiatry, 81(2), 6789. https://www.psychiatrist.com/jcp/evidence-based-treatment-of-pmdd/

Cortese, S. (2020). Pharmacologic treatment of attention deficit–hyperactivity disorder. New England Journal of Medicine, 383(11), 1050–1056. https://www.nejm.org/doi/full/10.1056/NEJMra1917069

Marx, W., Penninx, B. W., Solmi, M., Furukawa, T. A., Firth, J., Carvalho, A. F., & Berk, M. (2023). Major depressive disorder. Nature Reviews Disease Primers, 9(1), 44. https://doi.org/10.1038/s41572-023-00454-1

Nilsson, J., Sigström, R., Östling, S., Waern, M., & Skoog, I. (2019). Changes in the expression of worries, anxiety, and generalized anxiety disorder with increasing age: A population study of 70 to 85‐year‐olds. International Journal of Geriatric Psychiatry, 34(2), 249-257. https://doi.org/10.1002/gps.5012

Stein, D. J., Costa, D. L., Lochner, C., Miguel, E. C., Reddy, Y. J., Shavitt, R. G., & Simpson, H. B. (2019). Obsessive–compulsive disorder. Nature reviews Disease primers, 5(1), 52. https://doi.org/10.1038/s41572-019-0102-3

Also Read: NURS 6003 Academic Success And Professional Development Plan Part 1