PRAC 6665 Focused Soap Note and Patient Case Presentation, Part 2 Paper

PRAC 6665 Focused Soap Note and Patient Case Presentation, Part 2 Paper

PRAC 6665 Focused Soap Note and Patient Case Presentation, Part 2 Sample Paper

Subjective:

CC (chief complaint): “I want to go home.”

HPI: P.B. is a 27-year-old AA female on psychiatric evaluation after incarceration. She had taken her godson and son to the hospital, and when she learned of the godson’s injuries, she was separated from the children. She ran and was picked up on Friday by the police. Her son was taken from her by family services. She was placed in PCO III. The patient reports that his boyfriend abused the godson leading to the injuries. P.B. states that the boyfriend has emotionally manipulative behaviors, like following her and threatening to kill himself if she left him. He threatened to kill her if she told anyone about his abuse of her godson, whom she swears she never laid a hand on at all. She was arrested because she did not tell anyone and feared her boyfriend’s threats.

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Substance Current Use: Admits smoking marijuana.

Mental health history: No significant mental health history.

Medical History: No history of chronic illnesses.

• Current Medications: No current meds
• Allergies:

• Reproductive Hx: Para 1+2. Had complications with previous pregnancies but did not want to talk about them.

Family Psychiatric History: The grandmother has a history of depression and bipolar disorder and is on medication.

Social history: The client attended school up to 9th grade but is working on her GED. She dropped school after getting pregnant. She has never had a job, and her family financially supports her. She is single and has a son whom she is separated from after family services took him. The client was raised by her grandmother, lived with her mother once after getting pregnant, and returned to the granny. She mentions that her grandmother is essentially her only maternal figure. She reports a history of molestation as an infant by an adult male cousin until she was about 3 to 4 years old. The family reported hi8m, but her mother helped him escape. Her current stressors are not being able to go home. Her support system includes her good friend, mother, grandmother, sisters, and brothers. This is her first incarceration.

ROS:

• GENERAL: No fever, fatigue, or weight changes.
• HEENT: No eye pain, ear discharge, hearing loss, nasal discharge, or sore throat.
• SKIN: No skin rashes or lesions.
• CARDIOVASCULAR: No palpitations, dyspnea, or chest pain.
• RESPIRATORY: No cough, wheezing, or sputum.
• GASTROINTESTINAL: No GI distress, bowel changes, or rectal bleeding.
• GENITOURINARY: No dysuria, PV discharge, or pelvic pain.
• NEUROLOGICAL: No headaches, muscle weakness, or dizziness.
• MUSCULOSKELETAL: No limitations in movement.
• HEMATOLOGIC: No bleeding or bruising.
• LYMPHATICS: Denies lymph node swelling.
• ENDOCRINOLOGIC: Denies endocrine symptoms.

Objective: No pertinent physical exam findings.

Diagnostic results: No tests were ordered.

Assessment:

Mental Status Examination:

The patient is neat and clean. She maintains good eye contact and is cooperative. She is alert and oriented to person, place, time, and event. Her mood is labile and somewhat euthymic, and affect is appropriate. Her thought process is goal-directed, logical, and coherent. Thought content is appropriate with no suicidal/self-injurious ideation or homicidal/assaultive ideations. Denies hallucinations, obsessions, or delusions. Insight and judgment are fair.

Diagnostic Impression:

Generalized Anxiety Disorder (GAD): GAD typically presents with excessive anxiety or worry about various factors for not less than three months. Other features in the DSM V criteria include at least three of the following: Easy fatigue; Restlessness, feeling keyed up or on edge; Concentration difficulties; Irritability; Muscle tension; Sleep disturbance (DeMartini et al., 2019). GAD is a likely diagnosis based on the patient being anxious about her incarceration. She is stressed that she may never get out of prison. Besides, her anxiety can be attributed to the threats from his boyfriend.

Post-traumatic stress Disorder (PTSD): PTSD commonly occurs after experiencing or witnessing a traumatic event. The DSM V diagnostic criteria for PTSD include intrusive symptoms, avoidance symptoms, altered cognition and mood, and impaired arousal and reactivity (Bryant, 2019). The patient has a history of sexual abuse in her childhood perpetrated by an older cousin. She exhibits avoidance symptoms when she states that she remembers just some of the abuse but avoids thinking about it because it was terrible. She seems to have forgotten most details of the trauma, which is consistent with negative alterations in cognition.

Major Depression: The primary features of major depression are a depressed, sad, or tearful mood and diminished interest or loss of pleasure in activities. Patients are usually in a tearful mood and feel hopeless and helpless (Christensen et al., 2020). The patient is labile and sad because of being incarcerated and separated from her son. Besides, she feels hopeless and helpless in prison, making major depression a differential.

Reflections:

The patient assessment has enlightened me that incarcerated persons often experience depressive disorders, anxiety disorders, or PTSD. Exposure to prisons and jails can be traumatizing. It can worsen existing mental health problems or lead to PTSD symptoms like avoidance, hypersensitivity, anxiety, depression, hypervigilance, flashbacks, difficulty regulating emotions, and suicidality (Quandt & Jones, 2021). In a different situation, I would assess the patient for anxiety and depressive symptoms using tools like GAD-7 and PHQ-9. This is because incarceration is associated with mood disorders like major depressive disorder and bipolar disorder.

Case Formulation and Treatment Plan:

The patient’s major stressor is being unable to go home after being arrested for her boyfriend’s crime. She is emotionally concerned about going home, and her current goal is to be released. The priority diagnosis is GAD.

Treatment:

Escitalopram (Lexapro) 10 mg orally once daily. This is FDA-approved to treat GAD in adults in the acute phase. It also has an antidepressant effect. Wang et al. (2018) found Lexapro to be efficacious in alleviating depression and anxiety symptoms and improving patients’ social function and QoL.

Alternative: Effexor XR 37.5 mg orally once daily. Effexor is FDA-approved to treat GAD and effectively alleviates anxiety symptoms (Strawn et al., 2018).

Plan for follow-up: The patient will be followed up after four weeks to assess the medication’s impact in alleviating anxiety and the patient’s tolerance to medication (Strawn et al., 2018).

Referrals: Refer to a psychiatrist if symptoms worsen despite medication adherence.

Social Determinant of Health: Incarceration is a health threat to this patient which may worsen her physical and mental health. The prison environment can innately damage the patient’s mental health since she has been removed from society, eliminating a person’s meaning and purpose (Quandt & Jones, 2021).

Health promotion and patient education: Health promotion will focus on training the patient coping mechanisms to manage boredom and loneliness in prison. Health education will include educating the patient on personal hygiene measures to prevent infectious diseases associated with overcrowding in prison.

References

Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. World Psychiatry, 18(3), 259–269. https://doi.org/10.1002/wps.20656

Christensen, M. C., Wong, C., & Baune, B. T. (2020). Symptoms of Major Depressive Disorder and Their Impact on Psychosocial Functioning in the Different Phases of the Disease: Do the Perspectives of Patients and Healthcare Providers Differ? Frontiers in psychiatry, 11, 280. https://doi.org/10.3389/fpsyt.2020.00280

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

Quandt, K. R., & Jones, A. (2021). Research Roundup: Incarceration Can Cause Lasting Damage to Mental Health. Prison Policy Initiative.

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966

Wang, G., You, X., Wang, X., Xu, X., Bai, L., Xie, J., Yao, Z., Yi, Q., Ma, J., Wang, J., Zhuo, J., & Hu, C. (2018). Safety and effectiveness of escitalopram in an 8-week open study in Chinese patients with depression and anxiety. Neuropsychiatric disease and treatment, 14, 2087–2097. https://doi.org/10.2147/NDT.S164673

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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.

• 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:
  • When you submit your note, you should include the complete focused SOAP note as a Word document
  • You must submit your SOAP note using Turnitin.
• Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.

• 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 is supported by the patient’s symptoms.
• Plan: describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session? 
• In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
• 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.

USE THE BACKGROUND INFO PROVIDED, IF PERTINENT INFO IS MISSING IT IS OKAY FOR YOU TO CREATE IT.

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PRAC_6665_Week3_Assignment2_Pt1_Rubric

Criteria  Rating   Pts

This criterion is linked to a Learning Outcome

Discuss

Subjective data: • Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS

10 to >8.0 pts

Excellent

The video accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

10 pts

This criterion is linked to a Learning Outcome

Discuss

Objective data: • 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.

10 to >8.0 pts

Excellent

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

10 pts

This criterion is linked to a Learning Outcome

Discuss results of

Assessment: • Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.

20 to >17.0 pts

Excellent

The video accurately documents the results of the mental status exam. The video presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

20 pts

This criterion is linked to a Learning Outcome

Discuss

Treatment Plan: • A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research.

The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the Healthy People 2030, one health promotion activity, and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health.

20 to >17.0 pts

Excellent

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by valid research. … Discussion includes a clear and concise follow-up plan and parameters…. The discussion includes a clear and concise referral plan. … The paper discussion contains all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the Healthy People 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field.

20 pts

This criterion is linked to a Learning Outcome

Reflect on this case. Discuss what you learned and what you might do differently.

5 to >4.0 pts

Excellent

Reflections are thorough, and thoughtful, and demonstrate critical thinking.

5 pts

 

PRAC_6665_Week3_Assignment2_Pt2_Rubric

Criteria  Rating   Pts

This criterion is linked to a Learning Outcome

Focused SOAP Note documentation.

20 to >17.0 pts

Excellent

The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case. The preceptor’s signature and date pdf/image is uploaded on the completed assignment (not an electronic signature).

20 pts

Total Points: 20