Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting w

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Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders

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.
  • 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)

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-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.).

Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting w
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6665: PMHNP Care Across the Lifespan I Faculty Name Assignment Due Date Subjective: CC (chief complaint): HPI: Substance Current Use: Medical History: Current Medications: Allergies: Reproductive Hx: ROS: GENERAL: HEENT: SKIN: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: GENITOURINARY: NEUROLOGICAL: MUSCULOSKELETAL: HEMATOLOGIC: LYMPHATICS: ENDOCRINOLOGIC: Objective: Diagnostic results: Assessment: Mental Status Examination: Diagnostic Impression: Reflections: Case Formulation and Treatment Plan:  References © 2021 Walden University Page 3 of 3
Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting w
NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar 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. 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. Read rating descriptions to see the grading standards! 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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!), social determinates of health, 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.). (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. 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: 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. 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. 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. 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). 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.  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!), social determinates of health, 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). Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. 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. (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) 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. Be sure to use correct APA 7th edition formatting. © 2022 Walden University Page 7 of 7
Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting w
This study source was downloaded by 100000830278995 from CourseHero.com on 09-22-2022 13:00:14 GMT -05:00 https://www.coursehero.com/file/112763998/Wk-4-Assgn-O-SOAP-mood-disorder-docx/ Week 4: Focused SOAP Note and Patient Case Presentation College of Nursing-PMHNP, Walden University NRNP 6665: PMHNP Care Across the Lifespan 1 This study source was downloaded by 100000830278995 from CourseHero.com on 09-22-2022 13:00:14 GMT -05:00 https://www.coursehero.com/file/112763998/Wk-4-Assgn-O-SOAP-mood-disorder-docx/Introduction An individual’s psychiatric examination should be complete and integrated. crucial in the development of a correct psychiatric diagnosis Facts must be gathered from numerous sources without bias in order to receive reliable knowledge. The goal of this assignment is to gain an understanding of important questions to ask during an assessment and how to effectively assess and diagnose a mood disorder based on information acquired from the patient and objective information obtained during an interview by the PMHNP. After interviewing the patient, the assessment was noted, and three differential diagnoses were developed based on the information gathered during the interview session. A PMHNP was referred to a 26-year-old White female patient for treatment and continued management of her mental health problem. CC: “I have a history of taking medications and stopping them; I think the medication squashes who I am”. HPI : J.P a 26-year-old White female who came in for medication management. Patient is currently taking Zoloft which she complains made her high when she is creative and while sleeping her mind will be racing. She also takes Risperidone which made her gain weight. Takes Seroquel which made her gain weight as well, Klonopin, she complained it slowed her down. Because of the above listed discomfort and side effects patient listed, patient stopped taking the medication. Substance History or Current use: Nicotine: smoke about a pack cigarette a day and will not quit. Alcohol: admits to drinking alcohol but that was 19 years ago. Used marijuana some This study source was downloaded by 100000830278995 from CourseHero.com on 09-22-2022 13:00:14 GMT -05:00 https://www.coursehero.com/file/112763998/Wk-4-Assgn-O-SOAP-mood-disorder-docx/years ago and got paranoid, stopped smoking it. Cocaine and other stimulants: denies use. Caffeine: denies. Sedatives: Denies. Denies use of mushrooms. Denies use of pain pills or street drugs. Denies use of any type of ecstasy drugs. Family Psychiatric: M other had bipolar, Father was arrested and had jail time in prison due to drugs for 10 years now. Brother has schizophrenia but never went to hospital for treatment. No family history of suicide. Patient admits that she tried to kill herself once in the past but I won’t do it again. Psycho-social History: Lives: lives with her mother and sometimes her boyfriend. Goes over to her mother if her boyfriend’s gets mad at her for sleeping around. Work: employed; works with aunt’s bookstore. Misses work when she is feeling low. Education: in school for cosmetology to do make up for movie stars. Fun activities: writing her life story, paints Picasso. Arrest: police picked patient up and took her the hospital that she was found dancing naked. Trauma: Father was pretty tough and yelled at them a lot. Raised by mother and older brother. Hospitalization: Patient have been admitted four times. Admitted for suicide ideation: overdosed with Benadryl in 2017. When patient was a teenager, went for some days without sleeping. They gave patient some medication in the hospital that she can’t remember the name. Psychiatric History: Depression, Anxiety, Bipolar. Depression: get depressed for about 4 to 5 times a year; when patient does not have any energy or creativity then patient feels depressed and not want to do anything. During those episodes, are times when patient does not take her medication. Patient denies being having anxiety at this time. Denies repetitive episodes or OCD. Denies AVH/Delusions. Only hallucinates when she is not sleeping well; she hears voice. But none at this time. Appetite: when creative she is too busy to eat, when she is crashing, she eats a This study source was downloaded by 100000830278995 from CourseHero.com on 09-22-2022 13:00:14 GMT -05:00 https://www.coursehero.com/file/112763998/Wk-4-Assgn-O-SOAP-mood-disorder-docx/lot. Bad dreams: denies bad dreams. Sleep: 5 to 6 hours. When creative sleeps for 3 hours a week. When crashing can sleep for 12 to 16 hours a day. Current Medication: Zoloft, Risperidone, Seroquel, Klonopin, pregnancy control pill Allergies: NKDA Reproductive History: patient is sexually active. Patient states that she likes to have a lot of sex and it makes her feel high. Takes birth control pill for PCO. Her birth control is regular type. Medical history: Hypothyroidism, PCO ROS: GENERAL: feeling warm, no chills, no fatigue HEENT: Eyes: Vision intact, yellow sclerae. Ears: positive earache, positive hard of hearing, Nose: denies runny nose, sneezing, or congestion, Throat: no sore throat. SKIN: Warm to touch, No rash CARDIOVASCULAR: No chest pain, No palpitations, or edema. RESPIRATORY: No shortness of breath, negative for cough or hemoptysis GASTROINTESTINAL: Occasional constipation, No nausea, vomiting, or diarrhea. No abdominal pain, no blood stool GENITOURINARY: denies any problem with urination or bladder NEUROLOGICAL: frequent headache, no syncope, numbness, or tingling in the extremities. MUSCULOSKELETAL: occasional should and back pain, No muscle, joint pain, or stiffness. HEMATOLOGIC: No anemia or bleeding disorder LYMPHATICS: No enlarged nodes. PSYCHIATRIC: a history of bipolar, depression This study source was downloaded by 100000830278995 from CourseHero.com on 09-22-2022 13:00:14 GMT -05:00 https://www.coursehero.com/file/112763998/Wk-4-Assgn-O-SOAP-mood-disorder-docx/ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia. Diagnostic results : No diagnostic test or labs needed during the session Assessment Mental Status Examination J.P. is orientated four times. During the interview, you must be able to correctly answer questions, follow orders, and remain alert. She is also nice and neurologically sound. Her mood is balanced but dysthymic. She responds to all questions and goes into great depth when necessary. Although there were no acute psychosis or mood symptoms, the patient appeared concerned. Denies any current or previous history of suicide. Denies having any homicidal ideas or hearing voices or thoughts that might cause harm to people. All of your memories are still intact. Diagnostic Impression Bipolar Disorder: The following diagnosis is based on the information supplied and is subject to change as new data becomes available during later sessions. Bipolar disorder also known as manic-depressive illness or manic depression, is a mental condition that causes erratic mood swings, energy, activity levels, focus, and the ability to perform daily chores. People with bipolar illness have times of exceptionally high mood, changes in sleep patterns and activity levels, and uncommon actions, which they don’t always recognize as harmful or undesired. The term “mood episodes” refers to these separate intervals (Bachem & Casey, 2018). To be diagnosed with a bipolar disorder, an individual must meet specific criteria, according to the DSM-5. Within two weeks, the patient must experience 5 or more of the following symptoms: A distinct time of abnormally and persistently high, expansive, or irritable mood, as well as abnormally and This study source was downloaded by 100000830278995 from CourseHero.com on 09-22-2022 13:00:14 GMT -05:00 https://www.coursehero.com/file/112763998/Wk-4-Assgn-O-SOAP-mood-disorder-docx/persistently heightened activity or energy, that lasts at least 4 days and is present virtually every day (American Psychiatric Association, 2013). Our patient J.P presented with symptoms and behavior that correlates with the above listed symptoms: patient states that she get depressed for about 4 to 5 times a year; when patient does not have any energy or creativity then patient feels depressed and not want to do anything. During those episodes, are times when patient does not take her medication. Patient states that she likes to have a lot of sex with different people, even though she has a boyfriend, that it makes her feel high. Patient smoke about a pack cigarette a day, said she is planning to quit. Admitted for suicide ideation: overdosed with Benadryl. Patients works in her aunt’s bookstores but can stay away as she likes she does not feel like it. Borderline Personality Disorder: Borderline Personality Disorder is a major mental health condition with no recognized etiology. Individuals with Borderline Personality Disorder have continuous mood swings, self-image issues, impulsive behavior, and trouble relating to others, even animals (Sadock, et al., 2015). A pattern of changing moods, self-image, and behavior characterizes borderline personality disorder. Impulsive behavior and relationship issues are common outcomes of these symptoms. Anger, despair, and anxiety can persist anywhere from a few hours to days in people with borderline personality disorder. According to the DSM-5, the patient must have experienced these symptoms for at least 6 months: disabling episodes of anger, depression, and anxiety that last for hours or days, problems controlling anger, difficulty trusting, irrational fear of other people’s intentions, feelings of dissociation, and feelings of emptiness; intense episodes of anger, depression, and anxiety that last for hours or days; problems controlling anger, difficulty trusting, irrational fear of other people’s intentions, feelings of dissoci (American Psychiatric Association, 2013). The above-listed symptoms are evident in J.P our patient as evidenced by patient get depressed for about 4 to 5 times a year; when This study source was downloaded by 100000830278995 from CourseHero.com on 09-22-2022 13:00:14 GMT -05:00 https://www.coursehero.com/file/112763998/Wk-4-Assgn-O-SOAP-mood-disorder-docx/ Powered by TCPDF (www.tcpdf.org)patient does not have any energy or creativity then patient feels depressed and not want to do anything. During those episodes, are times when patient does not take her medication. Patient states that she likes to have a lot of sex with different people, even though she has a boyfriend, that it makes her feel high. Patient smoke about a pack cigarette a day, said she is planning to quit. Admitted for suicide ideation: overdosed with Benadryl. Patients works in her aunt’s bookstores but can stay away as she likes she does not feel like it. Generalized Anxiety Disorder: Reflection CBT treatment recommendation Case Formulation and Treatment Plan

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