NRNP 6665: PMHNP Care Across the Lifespan I
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.
PRAC 6665 WEEK 3 Assignment 2: 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 for 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 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 for 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.
Kraus, 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