PRAC 6665 Week 3: Focused SOAP Note and Patient Case Presentation Paper, Part 1

PRAC 6665 Week 3: Focused SOAP Note and Patient Case Presentation Paper, Part 1

PRAC 6665 Week 3: Focused SOAP Note and Patient Case Presentation Paper, Part 1

Subjective:

CC (chief complaint): “Psychiatric evaluation”

HPI: M.N., a 38-year-old female patient, is being watched and evaluated at the bedside. A medication review is being given while the nursing staff discusses her condition. The patient expresses feeling sick during a face-to-face assessment. The patient alleges to experience both visual and auditory hallucinations. The patient continues to express unease and insomnia and claims to have seen people who are not present. The nursing staff asserts that the patient becomes aggressive and intentionally hurts other patients and staff. The patient is currently unable to contract to be safe. The patient takes medication as prescribed; there have been no grave adverse effects noted. The patient reports that the area makes her feel uneasy. The patient will continue to benefit from inpatient psychiatric treatment by experiencing less violence and psychosis.

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Substance Current Use: The patient discloses a history of abusing alcohol to get some sleep. denies using or abusing any illegal substances, including cigarettes.

Family Psychiatric/Substance Use History: The patient’s 5-year-old child is autistic, and her 11-year-old daughter experiences anxiety and suicidal thoughts. mother uses drugs and alcohol.

Psychosocial History: The patient’s relationship with her police officer spouse is open. Her husband violently abused her three years ago. They have two children, ages 11 and 5, who are both mentally ill. The client’s husband’s adultery resulted in the birth of their 11-year-old son. Her mother used drugs when she was a young child. One of the client’s brothers is presently serving a prison sentence after the patient’s younger sibling was killed 16 years ago. She alleges that one of her maternal uncles attacked her when she was a little child. She is working on herself right now to become a better mother.

Medical History: There was no prior medical history of any other conditions.

• Current Medications: The patient is unable to recall the names of the medications she is taking. She does, however, make it clear that she follows instructions.
• Allergies: There are no known allergic reactions.

• Reproductive Hx: Heterosexual. two girls were born normally after regular pregnancies. reports being HIV- and STD-free and having regular menstrual cycles.

ROS:

• GENERAL: denies experiencing a decrease in appetite, changes in weight, a fever, chills, or heat or cold sensitivity.
• HEENT: Head: She says she does not get headaches, fits, or vertigo. Eye: She disputes any itchiness, redness, discharge, or blurred vision that she may have had. Ear: She denies experiencing any ringing, pain, swelling, or discharge. She disputes that she has sinus discomfort, a runny nose, blood from the nose, or nasal congestion. She claims she does not have a sore throat, tooth problems, or swallowing troubles.
• SKIN: She disputes any changes in skin tone, itching, rashes, or rashes.
• CARDIOVASCULAR: She disputes any palpitations, chest pressure, breathlessness, arrhythmias, edema, or discomfort in her lower extremities.
• RESPIRATORY: She denies having sinusitis, coughing up phlegm, wheezing, congestion, trouble breathing, or quick breathing.
• GASTROINTESTINAL: denies experiencing stomach aches, nausea, bloating, reduced appetite, anorexia, constipation, diarrhea, or vomiting.
• GENITOURINARY: She denies having urine incontinence, hematuria, hesitation when peeing, dysuria, or a burning feeling.
• NEUROLOGICAL: She disputes any tingling or paralysis in her extremities, headache, fainting, dizziness, or numbness.
• MUSCULOSKELETAL: She disputes any joint stiffness, muscular, or back pain.
• HEMATOLOGIC: She denies having anemia or easy bleeding and bruising.
• LYMPHATICS: Lymphadenopathy and splenectomy are denied by her.
• ENDOCRINOLOGIC: She disputes having polyuria, polydipsia, or profuse perspiration.

Objective:

Diagnostic results: Regular screening exams such as a CBC, a basic metabolic panel, LFTs, a kidney function test, and a urinalysis for drug testing were requested. Alcohol Use Disorders Identification Test (AUDIT) and Beck Depression Inventory (BDI) should be used to support the patient’s diagnosis.

Assessment:

Mental Status Examination: The 38-year-old patient is appealing and appropriately dressed for her age. She has a strong sense of location, time, and person. The patient is acting in a typical manner. She cooperates and speaks clearly and casually the entire time. She is feeling depressed. She has good recall and a typical thought process. Her ability to function, however, has been significantly impaired. Her personality is dull. Her mind is scattered and jumbled. She does not comprehend. Her decision-making is poor. confirms both auditory and visual hallucinations. indicates possible harm to oneself and others as well as suicidal thoughts.

Diagnostic Impression: Depression, alcohol use disorder.

Differential Diagnoses:

1. Major depressive disorder with psychotic features: This mental disorder is characterized by mood disturbance that is accompanied by hallucinations, delusions, or both. Psychotic traits are present in over 18.5 percent of people with MDD (Yang et al., 2019). The patient admits to having depressive episodes that are followed by many audio and visual hallucinations. The client is also suicidal, which puts both herself and other people in danger.
2. Alcohol-induced depressive disorder: Diagnosing this disorder can be particularly challenging since they share traits, such as insomnia and psychomotor agitation, with alcohol withdrawal and depressive disorders (McHugh & Weiss, 2019). The DSM-5 distinguishes between a substance-induced disease and a fundamental depressive disorder depending on whether the drug is regarded to be etiologically linked to the symptoms. The patient confirms that they have a history of drinking too much alcohol, experiencing depressive symptoms, and sleeping poorly.
3. Schizoaffective Disorder: A patient must display an uninterrupted course of illness with at least one depressive episode, 1 manic episode, or one mixed episode in combination with symptoms that satisfy Criterion A for schizophrenia to meet the DSM-V diagnostic criteria for paranoid schizophrenia (Archibald, 2019). Even in the absence of significant mood symptoms, hallucinations or delusions have persisted for at least two weeks during the same disease. Along with suicidal ideation, the ability to harm oneself and many others, and aural and visual hallucinations, the patient has depressive episodes.

Reflections: The PMHNP did a great job of compiling the crucial patient history to back up the primary diagnosis. The patient has both depression and an alcohol use disorder. The patient’s auditory and visual hallucinations, however, suggest that her depressed illness may also be psychotic, according to the results of the mental status examination (Dold et al., 2019). The patient was supposed to give her permission to involve her spouse and a friend in the evaluation process. The PMHNP must uphold the patient’s right to privacy and confidentiality, which is why permission must be obtained before including anybody in the patient evaluation and treatment plan.

Case Formulation and Treatment Plan:

Diagnostic studies: The Positive & Negative Syndrome Scale (PANSS), the Beck Depression Inventory (BDI), and the Alcohol Use Disorders Identification Test (AUDIT) are all psychological tests recommended for this patient (Dold et al., 2019).

Therapeutic interventions. Remind the patient to continue taking her current meds (McHugh & Weiss, 2019). Consider utilizing therapeutic strategies like CBT and mindfulness exercises.

Education: The client must be made aware of the need of adhering to her medicine and therapy plan for a positive outcome (Yang et al., 2019). She should also be informed of the need for regular exercise, restful sleep, and a nutritious diet in preserving her mental health.

Referrals: A psychiatrist should be seen if the patient is not benefiting from their current therapy or if there are any exacerbating comorbidities, such as suicidality (Voineskos et al., 2020).

Follow-up: After one to two months, reassess the patient’s treatment strategy based on the outcomes of the initial intervention (Voineskos et al., 2020).

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning.

References

Archibald, L. (2019). Alcohol Use Disorder Schizophrenia and Schizoaffective� Disorders. Alcohol Research: Current Reviews, 40(1). https://doi.org/10.35946/arcr.v40.1.06

Dold, M., Bartova, L., Kautzky, A., Porcelli, S., Montgomery, S., Zohar, J., Mendlewicz, J., Souery, D., Serretti, A., & Kasper, S. (2019). Psychotic Features in Patients With Major Depressive Disorder. The Journal of Clinical Psychiatry, 80(1). https://doi.org/10.4088/jcp.17m12090

McHugh, R. K., & Weiss, R. D. (2019). Alcohol Use Disorder and Depressive Disorders. Alcohol Research: Current Reviews, 40(1). https://doi.org/10.35946/arcr.v40.1.01

Voineskos, A. N., Mulsant, B. H., Dickie, E. W., Neufeld, N. H., Rothschild, A. J., Whyte, E. M., Meyers, B. S., Alexopoulos, G. S., Hoptman, M. J., Lerch, J. P., & Flint, A. J. (2020). Effects of antipsychotic medication on brain structure in patients with major depressive disorder and psychotic features: Neuroimaging findings in the context of a randomized placebo-controlled clinical trial. JAMA Psychiatry, 77(7). https://doi.org/10.1001/jamapsychiatry.2020.0036

Yang, W., Zhang, G., Jia, Q., Qian, Z.-K., Yin, G., Zhu, X., Alnatour, O. I., Trinh, T. H., Wu, H. E., Lang, X., Du, X., & Zhang, X. (2019). Prevalence and clinical profiles of comorbid anxiety in the first episode and drug naïve patients with major depressive disorder. Journal of Affective Disorders, 257, 200–206. https://doi.org/10.1016/j.jad.2019.06.052

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Focused SOAP Note and Patient Case Presentation, Part 1   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. Resources Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources. WEEKLY RESOURCES Learning Resources Required Readings Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer. Section II. The Psychiatric History (Chapters 14–18) Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms (Chapters 23–24) Lorberg, B., Davico, C., Martsenkovskyi, D., & Vitiello, B. (2019). Principles in using psychotropic medication in children and adolescents. Links to an external site. In J. M. Rey & A. Martin (Eds), IACAPAP e-textbook of child and adolescent mental health (2019 ed., pp. 1–25). International Association for Child and Adolescent Psychiatry and Allied Professions. https://iacapap.org/_Resources/Persistent/45bdffb25befc353c9f61988e82105029504ab85/A.7-Psychopharmacology-2019.1.pdf Meditrek Links to an external site. https://edu.meditrek.com/Default.html Note: Use this link to log into Meditrek to report your clinical hours and patient encounters. Document: Focused SOAP Note Template Download Focused SOAP Note Template (Word document) Document: Focused SOAP Note Exemplar Download Focused SOAP Note Exemplar (Word document) Recommended Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer. 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. Please Note: All SOAP notes must be signed, by your Preceptor. Note: Electronic signatures are not accepted. When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor. You must submit your SOAP note using Turnitin. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy. Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record. Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning. Ensure that you have the appropriate lighting and equipment to record the presentation. The Assignment Record yourself presenting the complex case for your clinical patient. Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video. In your presentation: Dress professionally and present yourself in a professional manner. Display your photo ID at the start of the video when you introduce yourself. Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information). Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management. Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value. Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide: 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 supported by the patient’s symptoms. Plan: In your video, 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. By Day 7 of Week 3 Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of completed assignment signed by your Preceptor. submission information – Part 1: Video Submission To submit your video response entry: Click on Start Assignment near the top of the page. Next, click Text Entry and then click the Embed Kaltura Media button. Select your recorded video under My Media. Check the box for the End-User License Agreement and select Submit Assignment for review. submission information – Part 2: Focused SOAP Note Submission To submit Part 2 of this Assignment, click on the following link: Week 3 Assignment 2, Part 2 BUY A CUSTOM- PAPER HERE ON; PRAC 6665 Week 3: Focused SOAP Note and Patient Case Presentation Paper, Part 1 Rubric PRAC_6665_Week3_Assignment2_Pt1_Rubric PRAC_6665_Week3_Assignment2_Pt1_Rubric Criteria Ratings Pts This criterion is linked to a Learning Outcome Photo ID display and professional attire 5 to >0.0 ptsExcellent Photo ID is displayed. The student is dressed professionally. 0 ptsFair 0 ptsGood 0 ptsPoor Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally. 5 pts This criterion is linked to a Learning Outcome Time 5 to >0.0 ptsExcellent The video does not exceed the 8-minute time limit. 0 ptsFair 0 ptsGood 0 ptsPoor The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.) 5 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 ptsExcellent 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. 8 to >7.0 ptsGood The video accurately 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. 7 to >6.0 ptsFair The video 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, but is somewhat vague or contains minor inaccuracies. 6 to >0 ptsPoor The video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of 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. Or subjective documentation is missing. 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 ptsExcellent The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable. 8 to >7.0 ptsGood The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable. 7 to >6.0 ptsFair Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies. 6 to >0 ptsPoor The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing. 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 ptsExcellent The video accurately documents the results of the mental status exam. 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. 17 to >15.0 ptsGood The video adequately documents the results of the mental status exam. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria. 15 to >13.0 ptsFair The video presents the results of the mental status exam, with some vagueness or inaccuracy. Video presents three differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria. 13 to >0 ptsPoor The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing. 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 HealthyPeople 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 ptsExcellent 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 HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field. 17 to >15.0 ptsGood The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by vague or questionable research. … Discussion includes a clear follow-up plan and parameters…. The discussion includes a clear referral plan…. The paper discussion contains 2 of the elements from the assignment directions with one being a basic discussion of the case related to the HealthyPeople 2030 social health determinates. Clearly relates discussion to the psychiatric and mental health field. 15 to >13.0 ptsFair The response somewhat vaguely or inaccurately outlines a treatment plan for the patient that addresses psychopharmacologic agents without discussion of FDA approval and includes vague or inaccurate alternative treatments with little rationale discussed. … The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters…. The discussion is somewhat vague or inaccurate regarding a referral plan. … The paper discussion contains 1 of the required elements from the assignment directions which is the HealthyPeople 2030 social health determinates…. Somewhat vaguely or inaccurately relates discussion to the psychiatric and mental health field. 13 to >0 ptsPoor The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis. There is no mention of FDA approval for treatment choices or no research supported discussion. Alternative treatment discussion is missing. … Rationales for treatments are missing. … There is no discussion for follow-up and parameters. … There is no discussion of a referral plan. … The paper discussion is missing discussion relating to the psychiatric and mental health field or relates discussion to another specialty realm including medical co-morbidity illnesses. 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 ptsExcellent Reflections are thorough, thoughtful, and demonstrate critical thinking. 4 to >3.5 ptsGood Reflections demonstrate critical thinking. 3.5 to >3.0 ptsFair Reflections are somewhat general or do not demonstrate critical thinking. 3 to >0 ptsPoor Reflections are incomplete, inaccurate, or missing. 5 pts This criterion is linked to a Learning Outcome Presentation style 5 to >4.0 ptsExcellent Presentation style is exceptionally clear, professional, and focused. 4 to >3.5 ptsGood Presentation style is clear, professional, and focused. 3.5 to >3.0 ptsFair Presentation style is mostly clear, professional, and focused 3 to >0 ptsPoor Presentation style is unclear, unprofessional, and/or unfocused. 5 pts