Petunia Park case study – NRNP 6665 Week 4 Assignment

Petunia Park case study – NRNP 6665 Week 4 Assignment

Focused SOAP Psychiatric Evaluation

Subjective:

Chief Complaint:
Mr. P.P., a 38-year-old Caucasian male, presents with a chief complaint of persistent low mood, loss of interest in previously enjoyed activities, difficulty sleeping, and feelings of worthlessness. He describes these symptoms as ongoing for the past six months.

History of Present Illness (HPI):
Mr. P.P. reports that his current symptoms began gradually, with initial feelings of sadness, reduced energy, and a loss of appetite. He has trouble concentrating and making decisions, which is affecting his work performance. He also notices significant weight loss and a general feeling of hopelessness. Mr. P.P. states that he rarely leaves his apartment, and his sleep is disrupted, often waking up in the middle of the night.

Transcultural Nursing – Cultural Competence in the Health History and Physical Examination

Past Psychiatric History:
Mr. P.P. has no prior history of psychiatric diagnoses or treatment.

Medication Trials and Current Medications:
He has not been on any psychiatric medications in the past.

Psychotherapy or Previous Psychiatric Diagnosis:
Mr. P.P. has not received any psychotherapy or psychiatric diagnosis.

Pertinent Substance Use, Family Psychiatric/Substance Use, Social, and Medical History:
The patient denies any history of substance use. He reports a family history of depression in his maternal grandmother. His medical history is unremarkable.

Allergies:
No known allergies.

Review of Systems (ROS):

General: Reports significant weight loss, fatigue, and feelings of worthlessness.
Cardiovascular: No palpitations or chest pain.
Respiratory: No shortness of breath or cough.
Gastrointestinal: Decreased appetite with weight loss.
Neurological: Trouble concentrating.
Endocrinologic: No reports of excessive sweating, heat intolerance, or polyuria.

Objective:

Mental Status Examination:

Mr. P.P. is an alert and well-groomed man. He maintains eye contact and speaks coherently. His thought process is linear and goal-directed. He is oriented to person, place, and time. Mood is consistently low, and affect is constricted. He denies any hallucinations or delusional thinking. There is no evidence of suicidal or homicidal ideation. Cognition appears intact with no memory or concentration deficits.

Assessment:

Differential Diagnoses:

Major Depressive Disorder (MDD):

Mr. P.P. presents with hallmark symptoms of MDD, including depressed mood, anhedonia, weight loss, sleep disturbances, fatigue, difficulty concentrating, and feelings of worthlessness. These symptoms have persisted for at least two weeks and significantly impact his daily functioning.

Dysthymic Disorder (Persistent Depressive Disorder):

Although Mr. P.P.’s symptoms are consistent with MDD, the prolonged duration of six months may also suggest dysthymic disorder. However, the severity of his symptoms is significant, which aligns more with MDD.

Adjustment Disorder with Depressed Mood:

It is important to consider the possibility of an adjustment disorder, as Mr. P.P. reports that his symptoms began in response to unspecified stressors. However, the duration and severity of his symptoms are more in line with MDD.

Diagnostic Impression:
The primary diagnosis for Mr. P.P. is Major Depressive Disorder (MDD). This diagnosis aligns with the duration and severity of his symptoms and their significant impact on his daily life.

Reflection:
If I could conduct the session again, I would focus more on exploring any recent stressors and potential triggers for his depressive episode. Additionally, I would inquire about his support system and any recent life changes that might be contributing to his symptoms. In terms of legal/ethical considerations, I would ensure that Mr. P.P. fully understands the nature of his condition and the treatment options available. I would also discuss the importance of regular follow-up appointments and the potential risks and benefits of medication. Health promotion and disease prevention strategies would involve addressing any lifestyle factors that could exacerbate depression, such as sleep hygiene, physical activity, and a balanced diet.

Plan:

Treatment and Management:

Psychotherapy: Mr. P.P. will be referred to a cognitive-behavioral therapist for individual therapy sessions. Cognitive-behavioral therapy (CBT) has demonstrated effectiveness in treating MDD.

Pharmacologic Treatment:

Given the severity of his symptoms, I recommend initiating pharmacologic treatment with a selective serotonin reuptake inhibitor (SSRI). Sertraline will be prescribed at an initial dose of 50mg daily, with close monitoring for side effects and therapeutic response.

Health Promotion:

Emphasis will be placed on the importance of maintaining a balanced diet, engaging in regular physical activity, and improving sleep hygiene.

Patient Education:

Mr. P.P. will be educated about the potential side effects of sertraline and the importance of adhering to the prescribed medication regimen. He will also be informed about the importance of attending therapy sessions regularly.

Follow-Up:
Mr. P.P. will have a follow-up appointment in two weeks to assess his response to sertraline and discuss any side effects or concerns. Further follow-up appointments will be scheduled as needed to monitor his progress.

Focused Soap psychiatric evaluation Examplar ( Please this is just an example/template to follow. Do not copy)

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide. petunia park case study – NRNP 6665 Week 4 Assignment It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required.  After reviewing full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

• Chief complaint
• History of present illness (HPI)
• Past psychiatric history
• Medication trials and current medications
• Psychotherapy or previous psychiatric diagnosis
• Pertinent substance use, family psychiatric/substance use, social, and medical history
• Allergies
• ROS

Read rating descriptions to see the grading standards! 

In the Objective section, provide:

• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. petunia park case study – NRNP 6665 Week 4 Assignment

Read rating descriptions to see the grading standards!

Depression			Premenstrual dysphoric disorder		Seasonal affective disorder (MDD with Seasonal Variation)
agomelatine amitriptyline amoxapine aripiprazole (adjunct) brexpiprazole (adjunct)bupropion citalopram clomipramine cyamemazine desipramine desvenlafaxine dothiepindoxepin duloxetine escitalopram fluoxetine fluvoxamine iloperidone imipramine isocarboxazid ketamine lithium (adjunct) l-methylfolate (adjunct)	lofepramine maprotiline mianserin milnacipran mirtazapine moclobemide nefazodone nortriptyline paroxetine phenelzine protriptyline quetiapine (adjunct) reboxetine selegiline sertindole sertraline sulpiride tianeptine tranylcypromine trazodone trimipramine venlafaxine vilazodone vortioxetine		citalopram desvenlafaxine duloxetin eescitalopram fluoxetin eparoxetine pepexev sarafe, sertraline venlafaxinepetunia park case study – NRNP 6665 Week 4 Assignment		Bupropion HCL extended-release
Bipolar depression	Bipolar disorder (mixed Mania/Depression			Bipolar maintenance	Mania
lithium (used with lurasidone) lurasidone olanzapine-fluoxetine combination (symbyax) quetiapine valproate (divalproex) (used with lurasidone)	aripiprazole asenapine carbamazepine	olanzapine ziprasidone		aripiprazole  lamotrigine lithium olanzapine	aripiprazole asenapine carbamazepine lithium olanzapine quetiapine risperidonevalproate (divalproex) ziprasidone

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form.
• At least three differentials with supporting evidence. List them from top priority to least priority. petunia park case study – NRNP 6665 Week 4 Assignment Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Read rating descriptions to see the grading standards!

Reflect on this case. Include: Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.) petunia park case study – NRNP 6665 Week 4 Assignment.

(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. petunia park case study – NRNP 6665 Week 4 Assignment. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example: petunia park case study – NRNP 6665 Week 4 Assignment

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures. petunia park case study – NRNP 6665 Week 4 Assignment.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum. petunia park case study – NRNP 6665 Week 4 Assignment.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. petunia park case study – NRNP 6665 Week 4 Assignment

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines) petunia park case study – NRNP 6665 Week 4 Assignment.

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good petunia park case study – NRNP 6665 Week 4 Assignment.

Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression.  You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression.  You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males) petunia park case study – NRNP 6665 Week 4 Assignment.

 

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. petunia park case study – NRNP 6665 Week 4 Assignment . Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

 

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

 

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

 

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal petunia park case study – NRNP 6665 Week 4 Assignment. (only if you or preceptor provided them)

 

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

 

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

 

Follow up with PCP as needed and/or for:

 

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education) petunia park case study – NRNP 6665 Week 4 Assignment

 

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

 

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses petunia park case study – NRNP 6665 Week 4 Assignment. Be sure to use correct APA 7th edition formatting.

 

In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

To Prepare

• Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
• Consider what history would be necessary to collect from this patient. petunia park case study – NRNP 6665 Week 4 Assignment
• Consider what interview questions you would need to ask this patient.

The Assignment

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

• Subjective: What details did the patient provide regarding their chief complaint and symptomatology 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 the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan:What is your plan for psychotherapy? What is 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 incorporate one health promotion activity and one patient education strategy. petunia park case study – NRNP 6665 Week 4 Assignment
• Reflection notes:What would you do differently with this client if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).