NRNP 6665: PMHNP Care Across the Lifespan I
Assignment 2: Focused SOAP Note and Patient Case Presentation (NRNP 6665)
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.
Week 3: Assignment 2: Focused SOAP Note and Patient Case Presentation
Subjective:
CC (chief complaint): “I have excessive fear and worry that have affected my health and wellbeing.”
HPI: A.K is a 24-year-old female that came to the clinic with complaints of excessive fear of unknown outcomes that may occur in her family and her academic performance. The client reported that the symptoms have persisted for the last six months. She was worried that the symptoms had increased in frequency and intensity, affecting her academic and social performance. She also reported that the symptoms were difficult for her to control. The accompanying symptoms of excessive worry and anxiety included restlessness, insomnia, easy fatigability, muscle pain, and impaired or difficulty in concentration. She could not attribute the symptoms to any medical problem, medication use, or psychiatric condition.
Substance Current Use: The client denies any current use of substances
Medical History:
- Current Medications: She is on Tylenol to manage pain in her left arm, which she hurt two days ago.
- Allergies: She reports allergic reaction to pollen.
- Reproductive Hx: She is single, with no pregnancy or pregnancy loss history. Her last menstrual period was 12/12/2021. The menstrual period is regular, without any abnormal symptoms. Her last gynecological examination was six months ago, which was normal. She denies an increase in urinary frequency and urgency. She denies any history of sexually transmitted diseases.
ROS:
- GENERAL: The client has dressed appropriately for the occasion. She has weight normal for her age. There is no evidence of fever 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 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 reports allergic reactions to pollen. She denies any other history of allergies.
Objective:
Diagnostic results: Laboratory and imaging studies should be performed to develop accurate diagnoses of the client’s problems. The studies help rule out other potential causes that could contribute to symptom development. One of the diagnostic investigations requested for the client is laboratory work for blood analysis. A complete blood count was ordered to determine if she had any other existing problems that required the attention of the healthcare providers. The other diagnostic investigation undertaken was the administration of psychological questionnaires. The General Anxiety Disorder-7 questionnaire was administered to determine if the client was suffering from an anxiety disorder. Severity Measure for Panic Disorder was also used to determine if she had a panic attack (Mossman et al., 2017). The diagnostic investigation was remarkable for the General Anxiety Disorder-7 tool.
Assessment:
Mental Status Examination: The patient appears well-groomed for the occasion. She is oriented to self, others, time, and events. Her thought content is future-oriented. She maintains normal eye contact during the assessment. She denies illusions, delusions, and hallucinations. Her self-reported mood is ‘anxious.’ Her speech is of normal rate, tone, and content. She denies suicidal thoughts, attempts, and plans.
Diagnostic Impression:
Generalized Anxiety Disorder: A.K.’s primary diagnosis is generalized anxiety disorder (GAD). GAD is characterized by extreme worry, even those with little reason for worry. Patients with the disorder experience anxiety of the possibility of harm befalling them. According to DSM-V, a diagnosis of generalized anxiety disorder is reached based on several symptoms. They include excessive worry and anxiety occurring in more days for at least six month-period and difficulties in controlling the worry (DeMartini et al., 2019). Patients also experience symptoms associated with anxiety that include restlessness, easy fatigue, difficulties in concentrating, and irritability. The use of diagnostic tools such as the Generalized Anxiety Disorder-7 questionnaire confirms the diagnosis (Mossman et al., 2017). A.K. experiences GAD symptoms, such as excessive fear and worry and its accompanying symptoms. As a result, GAD is A.K’s primary diagnosis.
Panic Disorder: Panic disorder is the secondary diagnosis that should be considered for A.K. Panic attack is an anxiety disorder characterized by patients experiencing unexpected panic attacks with no trigger. Patients report the rapid onset of extreme fear with accompanying symptoms such as sweating, palpitations, trembling, feelings of choking, and breathlessness. Patients also experience abdominal distress, dizziness, fear of death, derealization, chills, and numbness. Patients also express fear of further attacks and engage in avoidance behaviors (Pompoli et al., 2018). A.K does not exhibit the above symptoms, making panic attack the least likely diagnosis.
Insomnia: The other secondary diagnosis to be considered is insomnia. Insomnia is characterized by patients’ complaints of lack of quality and quantity of sleep. Patients also experience awakenings followed by difficulties in getting sleep afterward. However, patients do not experience excessive worry and anxiety (Burman, 2017). As a result, it rules out insomnia as the cause of A.K’s problem.
Reflections:
One of the things I would do differently if I could conduct the session again is explore further the patient’s experiences with the symptoms. I will seek further information from the client about what she does to alleviate the symptoms. I will also seek information on the effect of the disorder on the client’s quality of life. I did not follow up with the client. My next intervention will be to make a follow-up phone call to determine her response to treatment.
Case Formulation and Treatment Plan: A.K. is a 24-year-old client who came to the clinic with excessive worry and anxiety complaints. She did not attribute the symptoms to substance abuse, medical condition, or medication use. She was diagnosed with generalized anxiety disorder. She was initiated on group psychotherapy. She was scheduled for a follow-up visit after one month.
References
Burman, D. (2017). Sleep Disorders: Insomnia. FP Essentials, 460, 22–28.
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of Internal Medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020
Mossman, S. A., Luft, M. J., Schroeder, H. K., Varney, S. T., Fleck, D. E., Barzman, D. H., Gilman, R., DelBello, M. P., & Strawn, J. R. (2017). The Generalized Anxiety Disorder 7-item (GAD-7) scale in adolescents with generalized anxiety disorder: Signal detection and validation. Annals of Clinical Psychiatry : Official Journal of the American Academy of Clinical Psychiatrists, 29(4), 227-234A.
Pompoli, A., Furukawa, T. A., Efthimiou, O., Imai, H., Tajika, A., & Salanti, G. (2018). Dismantling cognitive-behaviour therapy for panic disorder: A systematic review and component network meta-analysis. Psychological Medicine, 48(12), 1945–1953. https://doi.org/10.1017/S0033291717003919