Petunia Park Case Study – NRNP 6665 Week 4 Assignment Paper

Petunia Park Case Study – NRNP 6665 Week 4 Assignment Paper

Subjective:

CC (chief complaint):

HPI: Petunia Park is a 25-year-old female who has come today for a mental health assessment. She reports having a history of taking medications but not adhering to them. She usually stops taking the meds because they crush her. When she was a teenager, her mother took her to the hospital after failing to sleep for 4-5 days. She was initiated on some meds because she was hearing things. The patient reports that she finds it exciting and thrilling to find new people to explore sex with because it keeps her mood high.

The patient gets into depression 4-5 times a year, which makes her not work at her aunt’s bookstore. When depressed, she has no energy and lacks the motivation to engage in any activity. She mentions that she lacks interest in her creative work, which makes her feel worthless. The lack of motivation and creativity occurs after five days of working hard in writing, painting, and music. She feels that this is caused by exhaustion rather than being depressed. She reports loving her creative episodes that occur for a week before she crushes. During these episodes, she has much energy, sleeps very little, and engages in much work. Her friends say that she talks excessively and looks disorganized. Besides, she explores her body and mind through sexual encounters with others. Petunia also states that at times when she is not sleeping well, she hears voices telling her she is great and wonderfully talented. When creative, she hardly eats and sleeps 3-4 hours/week, but when crushed, she overeats and sleeps 12-16 hrs/day.

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Substance Current Use: Smokes 1PPD. Her last alcoholic drink was at 19 years. She tried marijuana once, and she had paranoia. She denies using other drug substances.

Medical History: Has hypothyroidism

 

• Current Medications: Hypothyroidism medications and birth control pills.
• Allergies: None

• Reproductive Hx: Positive history of polycystic ovaries. Has regular menses.

ROS:

• GENERAL: Increased energy levels when creative. Low energy levels when crushed.
• HEENT: No visual changes, hearing loss, nasal drip, or sore throat.
• SKIN: No discoloration or bruises.
• CARDIOVASCULAR: No chest pain or dyspnea.
• RESPIRATORY: No cough, wheezing, or breathing difficulties.
• GASTROINTESTINAL: Increased appetite when crushed; Lack of appetite during creative episodes.
• GENITOURINARY: Denies dysuria, blood in urine, or abnormal vaginal discharge.
• NEUROLOGICAL: Denies headaches, drowsiness, paralysis, or
• MUSCULOSKELETAL: Denies muscle pain, back pain, or joint stiffness.
• HEMATOLOGIC: No bruising or bleeding.
• LYMPHATICS: No lymph enlargement.
• ENDOCRINOLOGIC: No acute thirst, excessive sweating, or polyuria.

Objective:

Temp 98.2; Pulse- 90; Respiration-18; B/P-138/88

Diagnostic results: Urine drug and alcohol screen- negative.

CBC- within normal ranges

CMP- within normal ranges

Lipid panel- within normal ranges.

Prolactin Level- 8; TSH- 6.3 (H)

Assessment:

Mental Status Examination:

The client is dressed in bright, vibrant-colored clothing and wears heavy makeup. She had long, disheveled hair and was unkempt. She is alert and oriented to person, place, and time. She has clear, coherent, and goal-directed speech. Her thought process is coherent and logical. Delusions of grandeur noted (states that she paints like Picasso). No current hallucinations, obsessions, or suicidal thoughts. Intact memory and judgment.

Diagnostic Impression:

Bipolar 1 Disorder: Bipolar 1 disorder is diagnosed based on the presence of a manic episode that is preceded by and may be followed by hypomania or major depressive episodes Novick, D. M., & Swartz, H. A. (2019). Petunia has a history of a manic episode in her creative days that lasts a week and is followed by a major depressive episode. The patient’s manic episode manifests with: an elevated mood, increased goal-directed activity, grandiosity, reduced need for sleep, being more talkative, looking disorganized, and involvement in sexual indiscretions Novick, D. M., & Swartz, H. A. (2019). This occurred for a week and was followed by a depressive episode with a lack of interest in pleasurable activities, low energy levels, lack of motivation, hypersomnia, and increased appetite.

Schizophrenia: The DSM-V diagnostic criterion for schizophrenia includes two or more of the following present for at least one month: Delusions, Hallucinations, Disorganized speech, grossly disorganized or catatonic behavior, and Negative symptoms. At least one of the symptoms must be hallucinations, delusions, or disorganized speech (Ravichandran et al., 2020). The patient reports having auditory hallucinations when she has inadequate sleep and delusions of grandeur in the creative episodes. In addition, she experiences negative symptoms like avolition and anhedonia when crushed. Nevertheless, the patient also has manic and depressive symptoms that rule out schizophrenia as the primary diagnosis.

Major depression: Depression primary symptoms are a depressed mood or loss of interest/pleasure. The patient reports a loss of interest in things she enjoys doing when crushed. She also presents with other symptoms of depression when crushed, like hypersomnia, increased appetite, loss of energy, and feelings of worthlessness (Tolentino & Schmidt, 2018). However, this alternates with manic episodes, making major depression a less likely primary diagnosis.

Case Formulation and Treatment Plan:

Pharmacologic: Lithium ER 450 mg BD orally. Lithium is a first-line medication for long-term prophylaxis in bipolar illness. It is used for classic bipolar disorder with euphoric mania. It is also used to treat acute mania and is efficacious in preventing or relapsing episodes of either mania or depression (Shah et al., 2018).

Non-pharmacologic treatments: Cognitive behavioral therapy (CBT). CBT aims to educate the client about Bipolar disorder, teaching her cognitive behavioral skills for coping with the condition and psychosocial stressors and problems associated with the disease (Novick & Swartz, 2019). CBT will also seek to improve medication and treatment compliance.

Alternative therapies: Lamotrigine 25 mg PO once daily.

Lamotrigine is efficacious in the prevention of depressive episodes but not for manic episodes (Jain et al., 2022).

Follow-up parameters: Serum lithium levels will be monitored twice weekly in the acute treatment phase until the serum level and the patient’s clinical condition stabilizes (Shah et al., 2018).

Health promotion and patient education: Psychoeducation will address the importance of treatment adherence and identifying early signs of a new manic or depressive episode. Health education will target lifestyle modifications, including dietary changes, smoking cessation, and engaging in physical activity to lower the risk of metabolic side effects (Shah et al., 2018).

Reflection Notes:

If I were to conduct the session again, I would use Mania rating scales like the Young Mania Rating Scale to evaluate the severity of the patient’s manic symptoms. If I followed up with the patient, I would assess the treatment’s impact in alleviating manic symptoms and assess for side effects. I would also monitor the patient’s serum levels. Ethical considerations, in this case, surround the patient’s right to autonomy. The PMHNP should involve the patient in developing the treatment plan and respect her treatment preferences. This is crucial in promoting medication adherence. Bipolar medications are associated with metabolic side effects including weight gain. Thus, health promotion and education should focus on lifestyle modification to reduce the severity of these side effects.

References

Jain, R., Kong, A. M., Gillard, P., & Harrington, A. (2022). Treatment patterns among patients with bipolar disorder in the United States: a retrospective claims database analysis. Advances in Therapy, 39(6), 2578-2595.https://doi.org/10.1007/s12325-022-02112-6

Novick, D. M., & Swartz, H. A. (2019). Evidence-based psychotherapies for bipolar disorder. FOCUS, A Journal of the American Psychiatric Association, 17(3), 238-248. https://doi.org/10.1176/appi.focus.20190004

Ravichandran, C., Ongur, D., & Cohen, B. M. (2020). Clinical Features of Psychotic Disorders: Comparing Categorical and Dimensional Models. Psychiatric research and clinical practice, 3(1), 29–37. https://doi.org/10.1176/appi.prcp.20190053

Shah, N., Grover, S., & Rao, G. P. (2018). Clinical Practice Guidelines for Management of Bipolar Disorder. Indian journal of psychiatry, 59(Suppl 1), S51–S66. https://doi.org/10.4103/0019-5545.196974

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 Criteria and Depression Severity: Implications for Clinical Practice. Frontiers in psychiatry, 9, 450. https://doi.org/10.3389/fpsyt.2018.00450

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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.
• Consider what interview questions you would need to ask this patient.
• Consider patient diagnostics missing from the video:

 

Provider Review outside of interview:

Temp 98.2  Pulse  90 Respiration 18  B/P  138/88

Laboratory Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)

 

Assignment: Assessing, Diagnosing, and Treating Adults with 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 (You will find this under learning resources section)*** Follow this sample for your SOAP note. 

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.

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?

** Ensure this is detailed enough to formulate a diagnosis **

• 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 rule 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.

• 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.).

Extra Pertinent information that should be included on your SOAP Note. This is missing from the video. 

**********************************************

Provider Review: outside of the interview

Vital signs:

Temp 98.2  Pulse  90 Respiration 18  B/P  138/88

Laboratory Data Available:

Urine drug and alcohol screen- negative.  CBC- within normal ranges, CMP- within normal ranges. Lipid panel- within normal ranges. Prolactin Level- 8; TSH- 6.3 (H)

The patient presents with bright vibrant colored clothing and heavy makeup.   She had disheveled long hair and was unkept.

General Description to be used instead of avatar presentation:

Required Media

• CrashCourse. (2014, September 8). Depressive and bipolar disorders: Crash course psychology #30Links to an external site. [Video]. YouTube. https://youtu.be/ZwMlHkWKDwM https://www.youtube.com/watch?v=ZwMlHkWKDwM&t=1sLinks to an external site.
• Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://waldenu.instructure.com

 

Transcript from Case Study video:

[MUSIC PLAYING]

DR. MOORE: Hi. Good afternoon. My name is Dr. Moore. Am I understanding you’re here for a mental health assessment today?

PETUNIA PARK: That’s right.

DR. MOORE: OK. So to make sure I have the right patient and the right chart, can you tell me your name and your date of birth?

PETUNIA PARK: Yes. I’m Petunia Park. My birthday is July 1, 1995.

DR. MOORE: And can you tell me what today’s date is?

PETUNIA PARK: So it’s December 1.

DR. MOORE: Do you know the year?

PETUNIA PARK: 2020.

DR. MOORE: And what day of the week is this?

PETUNIA PARK: It’s Tuesday. [CHUCKLING]

DR. MOORE: And do you know where we are today?

PETUNIA PARK: Yes I am here in the beautiful, sunny office at the clinic.

DR. MOORE: OK, great. Thank you. So can you tell me a little bit about why you’re here today? What brings you here today?

PETUNIA PARK: Yes. So I have a history of taking medications and then stopping them. I don’t think I need them. I really feel like the medication squashes who I am.

DR. MOORE: OK, OK. So I’m going to be able to help you with that. But to begin, I’m going to ask you some questions about your family. I’m going to ask you some history-type questions. I’m going to ask you some symptoms that you might be having. And all of these questions are going to help me work with you on a treatment plan, OK? So I would like to begin with, when was the first time that you ever had any mental health or substance use treatment in your life?

PETUNIA PARK: OK. Well, when I was a teenager, my mom put me in the hospital after I went four or five days without sleeping. I think I may have been hearing things at that time. [CHUCKLES] I think they started me on some medication, but I’m not sure.

DR. MOORE: Oh, OK so you were hospitalized. How many times have you been hospitalized for mental health?

PETUNIA PARK: Oh, I’ve been hospitalized about four times. The last time was this past spring. No detox or residential rehabs, though.

DR. MOORE: OK, good. Were any of these hospitalizations due to any suicide gestures?

PETUNIA PARK: One was in 2017. I overdosed on Benadryl, but I’ve not had those thoughts since then.

DR. MOORE: Well, I’m very glad to hear that you’ve not had any of those thoughts since then. And I’m glad that you turned out OK from that overdose. I’m glad that you’re here today. Can you tell me a little bit about what you’ve been diagnosed with during your past treatments?

PETUNIA PARK: Well, I think depression, and anxiety, had some even say maybe bipolar.

DR. MOORE: OK, and what medications have you been tried on before for those illnesses? And if you can remember, what was your reactions to those medications?

PETUNIA PARK: Oh, let’s see. Oh, I took Zoloft, and that made me feel really high. [CHUCKLES] I couldn’t sleep. My mind was racing, and then I took risperidone. That made me gain a bunch of weight. Seroquel gave me weight, too. I took Klonopin, and that seems to slow me down some. I really can’t remember the others. I think the one I just stopped taking was helping. It started with an L, I think. I don’t really remember the name, but it squashed me in creativity.

DR. MOORE: OK, well, we’re going to try to help you find some medication that doesn’t make you feel squashed or have any of those negative side effects today. But in order to do that, I need some more information. And the next questions I’m going to ask you are about substances you may have used. And I want you to know that you don’t get in trouble in here if you’ve used some of these substances. It really just helps me to make sure that what’s in your system that could be impacting your neurochemistry. And when we do talk about medications, so I don’t give you something that would negatively interact with something you may be using, OK? So do you–

PETUNIA PARK: OK.

DR. MOORE: –use any nicotine?

PETUNIA PARK: Yes. I smoke about a pack a day, and I’m not going to quit for you, either. [CHUCKLES] Oh.

DR. MOORE: That’s OK, that’s OK. And what about alcohol? When was your last drink of alcohol?

PETUNIA PARK: When I was 19 because alcohol and me do not work well together. [CHUCKLES]

DR. MOORE: OK, and what about any marijuana? When was your last use of any marijuana?

PETUNIA PARK: Oh no. I tried that once and got really paranoid.

DR. MOORE: OK. What about any last use of cocaine?

PETUNIA PARK: Never.

DR. MOORE: Last use of any stimulants or methamphetamines?

PETUNIA PARK: Never.

DR. MOORE: What about any huffing or inhalants?

PETUNIA PARK: Never.

DR. MOORE: OK, have you used anything like Klonopin or Xanax, any of those sedative medications?

PETUNIA PARK: Never.

DR. MOORE: All right, good. What about any hallucinogenics like LSD, or PCP, or mushrooms?

PETUNIA PARK: No, never.

DR. MOORE: Wonderful. OK, what about any use of pain pills or opiate medications? Anything prescribed or anything you’ve obtained from the street?

PETUNIA PARK: No, never.

DR. MOORE: Good. And anything synthetic like Spice, or ecstasy, Bath Salts, Mollies, anything like that?

PETUNIA PARK: Never.

DR. MOORE: Oh, wonderful. Well, I’m glad to hear that. You know those things aren’t good for your brain. So I encourage you to continue to stay away from those things. Have you ever had any blackouts or seizures from drugs or alcohol? Or seen things that you weren’t sure were there?

PETUNIA PARK: Never.

DR. MOORE: Good. What about any legal issues or any DUIs?

PETUNIA PARK: Never.

DR. MOORE: OK. Good, good. All right, so I’m just going to ask a little bit about your family right now. Any blood relatives have any mental health or substance abuse issues?

PETUNIA PARK: Yeah, well, well, why would you ask that? It’s not your business.

DR. MOORE: Right. I could see where you might find that wouldn’t be any my business. But really, sometimes these issues can be genetic. They’re alarm behaviors. So my understanding of your family helps me to understand you.

PETUNIA PARK: Huh. Well, my mother was seen as crazy. I think they said she had bipolar or something. And my father went to prison for drugs. And well, we haven’t heard, or seen, or heard from him in 8 or 10 years. My brother, while I think he’s a little schizo, but he hasn’t ever went to the doctor. Nobody else with anything.

DR. MOORE: OK. So that sounds like it must be tough growing up not seeing your father and having some of those issues in your family. But any family, or blood relatives commit suicide?

PETUNIA PARK: Well, my mom tried, but nobody really did it, you know?

DR. MOORE: OK. Have you ever done anything like that, or anything like cut on yourself, burn yourself?

PETUNIA PARK: I already told you, I tried to kill myself. Why ask me that again? No, I’m not going to kill myself or anyone else, and I don’t cut myself.

DR. MOORE: OK. Well, I’m glad to hear that. And I want you to know that I am here for you, and we most certainly will make sure you have a crisis-like number at the end of this session if you do have those thoughts in the future. So, I’m glad to hear that you don’t have those thoughts today. OK. What type of medical issues do you have?

PETUNIA PARK: Oh, hoo. Let’s see. I have a thyroid issue that I take some medicine for, that hypothyroidism. And I take a birth control pill for polycystic ovaries.

DR. MOORE: OK, when was your last menses?

PETUNIA PARK: Oh, well I have a regular one each month. So, let’s see. It was last month sometime.

DR. MOORE: OK, so any chance that you’re pregnant?

PETUNIA PARK: [LAUGHS] Lordy, no. I may have a lot of sex around, but I’m safe.

DR. MOORE: Hm. You “have a lot of sex around.” Can you maybe tell me what that means?

PETUNIA PARK: Well, it’s exciting and thrilling to find new people to explore sex with. It helps me keep my moods high, high, high. [CHUCKLES]

DR. MOORE: OK, so that makes you feel really high and kind of what, OK?

PETUNIA PARK: Oh yeah.

DR. MOORE: So, who raised you?

PETUNIA PARK: My mom and my older brother, mainly.

DR. MOORE: And who do you live with now?

PETUNIA PARK: Well, I live with my boyfriend. And sometimes, stay with my mom when he gets mad at me for sleeping around some.

DR. MOORE: So that’s created some issues in your relationship, I see. OK. Are you single, married, widowed, or divorced?

PETUNIA PARK: I’ve never been married.

DR. MOORE: OK. Do you have any children?

PETUNIA PARK: No.

DR. MOORE: All right. Are you working?

PETUNIA PARK: Yes, I work part-time at my aunt’s bookstore. She’s more tolerant of the days I don’t come in from feeling too depressed.

DR. MOORE: OK, so I hear some, maybe, feelings of depression. OK. What is your level of education?

PETUNIA PARK: Oh, I’m in vo-tech school right now for cosmetology. I’m going to do makeup for movie stars. [CHUCKLES]

DR. MOORE: Oh, that sounds really wonderful. OK, so but what about now? What do you do for fun now?

PETUNIA PARK: Well, I am writing my life story, and it’s going to be published. I also paint like Picasso. I’m going to sell those paintings to movie stars, too.

DR. MOORE: Well, that’s wonderful. Maybe someday you can show me your paintings as well. OK, have you ever been arrested or convicted for anything?

PETUNIA PARK: No. The police did pick me up and take me to the hospital once. I didn’t have much sleep that week. And they said I was dancing around in my nightgown in a field with my guitar. I really don’t remember much of that, though. I think maybe my mom made up that story against me because she wanted me to go back to my boyfriend’s house.

DR. MOORE: OK, so that was one of your hospitalizations that we talked about earlier. OK, what about any history of trauma in childhood or adulthood? Any kind of physical, sexual, or emotional abuse?

PETUNIA PARK: Well, my dad was pretty hard on us when he was around. But he didn’t really touch us or anything. More just yelled at us a lot.

DR. MOORE: OK. All right, so I’ve gathered some history here. Now, I want to get into more of some of the symptoms that brought you in to see me today. So you mentioned before that sometimes your depression keeps you from working at your aunt’s bookstore. Can you tell me a little bit more about what that looks like for you?

PETUNIA PARK: Well, about four or five times a year, I have these times when I just don’t want to get out of bed. I have no energy, no motivation to do anything. I just can’t feel any interest in my creativity. I feel like I’m not worth anything because I feel that creativity slipping away. So this is usually happening after I’ve been up for five days working hard on my works with my writing, painting, and music. Everyone says I’m depressed, but I’m not sure. It could be that I’m just exhausted from working so hard.

DR. MOORE: OK, so I hear you talking about these creativity episodes right before you crash. Per se, this depression. Tell me a little bit more about those episodes. What do those look like for you?

PETUNIA PARK: Oh, I love those times. Those are the reasons I don’t always take my medication because I feel like I’m squashed. I have lots of energy to do a lot of things. I can go four or five days with very little sleep. I get lots of things done, but my friends tell me I talk too much and appear scattered. [SIGHS] They’re just jealous of all the accomplishments I’m getting done. These are the times I look to explore my mind and body with feeling good through sex with other people.

DR. MOORE: OK, how long do those episodes last typically when you have them?

PETUNIA PARK: About a week.

DR. MOORE: About a week. OK. So, I want to ask a little bit more about some other symptoms that maybe we haven’t talked about. Do you feel like you worry a lot or have any kind of anxiety and panic symptoms?

PETUNIA PARK: No, no no. I’m not a worry.

DR. MOORE: OK, do you do anything that you feel like you have to do repetitively over and over? And if you can’t do them, you feel like the end of the world is coming? Something like maybe count on threes or wash your hands 20 times? Anything like that?

PETUNIA PARK: [LAUGHS] No, no. I don’t have OCD if that’s what you’re asking.

DR. MOORE: OK, what about hearing or seeing things you’re not sure

others see or hear? Anything like that?

PETUNIA PARK: Not right now. It’s been a couple of months since that happened. Sometimes when I’m not sleeping good, I hear voices telling me how great and wonderfully talented I am.

DR. MOORE: OK. So, but no voices right now?

PETUNIA PARK: No.

DR. MOORE: OK, good. What about your appetite? How’s your appetite?

PETUNIA PARK: Well, when I’m really creative, I’m too busy to eat. And when I’m

crashing and resting, I eat everything in sight.

DR. MOORE: OK, so what about your sleep? On average, how much time

do you think you sleep in a whole 24-hour period? And do you have any bad dreams?

PETUNIA PARK: No bad dreams. Most of the time, I get about five or six hours. When I’m creative, I’m lucky to get three hours and a whole week. Ugh. And when I’m crashed, I sleep about 12 or 16 hours a day.

DR. MOORE: OK, wonderful. So, this is great. I have a lot of information from you that I think we will be able to come up with a treatment plan and maybe find some medication that’s going to help you feel better without you feeling so squashed and having negative side effects, but really help you be able to function through the day.

[MUSIC PLAYING]

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?
• MUST Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority.
• Compare the DSM-5-TR 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.
• Reflection notes: Reflect on this case.
• 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!), social determinates of health, 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.).

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NRNP_6665_Week4_Assignment_Rubric

Criteria         Rating           Pts

This criterion is linked to Learning Outcomes:

Create documentation in the Focused SOAP Note Template about the patient in the case study.

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

15 to >13.0 pts

Excellent

The response thoroughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

15 pts

In the Objective section, provide:• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

15 to >13.0 pts

Excellent

The response thoroughly and accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

15 pts

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. 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.

20 to >17.0 pts

Excellent

The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

20 pts

In the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy.

25 to >22.0 pts

Excellent

The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding. … The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.

25 pts

Reflect on this case. 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!), social determinates of health, 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.).

5 to >4.0 pts

Excellent

Reflections are thorough, thoughtful, and demonstrate critical thinking.

5 pts

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

10 to >8.0 pts

Excellent

The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.

10 pts

Written Expression and Formatting – The paper follows the correct APA format for parenthetical/in-text citations and reference lists.

5 to >4.0 pts

Excellent

Uses correct APA format with no errors

5 pts

Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation

5 to >4.0 pts

Excellent

Uses correct grammar, spelling, and punctuation with no errors

5 pts

Total Points: 100

DO NOT INCLUDE THE TITLE PAGE, I WILL TAKE CARE OF THAT