Case Study transcript and video are in the attachments.
Develop a Focused SOAP Note, including a differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into the responses in the template:
- Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive at the differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations were made during the psychiatric assessment?
- Assessment: Discuss the patient’s mental status examination results. What were the differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest 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 to the primary diagnosis selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: What is the plan for psychotherapy? What is the 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 could be done differently with this patient if conducting the session again? Discuss what the next intervention would be if following up with this patient. Also include in the reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
- Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support the diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
Case Study: Dev Cordoba
© 2021 Walden University, LLC 1
Case Study: Dev Cordoba
DR. JENNY: Hi there. My name is Dr. Jenny. Can you tell me your name and how old
DEV CORDOBA: My name is Dev, and I am seven years old.
DR. JENNY: Wonderful. Dev, can you tell me what the month and the date is? And
where are we right now?
DEV CORDOBA: Today is St. Patrick’s Day. It’s March 17th.
DR. JENNY: Do you know where we are?
DEV CORDOBA: We’re at the school.
DR. JENNY: Good. Did your mom tell you why you’re here today to see me?
DEV CORDOBA: She thought you were going to help me be better.
DR. JENNY: Yes, I am here to help you. Have you ever come to see someone like me
before, or talked to someone like me before to help you with your mood?
DEV CORDOBA: No, never.
DR. JENNY: OK. Well, I would like to start with getting to know you a little bit better, if
that’s OK. What do you like to do for fun when you’re at home?
DEV CORDOBA: Oh, I have a dog. His name is Sparky. We play policeman in my
room. And I have LEGOs, and I could build something if you want.
DR. JENNY: I would love to see what you build with your LEGOs. Maybe you can bring
that in for me next appointment. Who lives in your home?
DEV CORDOBA: My mom and my baby brother and Sparky.
DR. JENNY: Do you help your mom with your brother?
DEV CORDOBA: No. His breath smells like bad milk all the time. [CHUCKLES] And he
cries a lot, and my mom spends more time with him.
DR. JENNY: So how do you feel most of the time? Do you feel sad or worried or mad or
DEV CORDOBA: Worried.
DR. JENNY: What types of things do you worry about?
Case Study: Dev Cordoba
© 2021 Walden University, LLC 2
DEV CORDOBA: I don’t know, just everything. I don’t know.
DR. JENNY: OK. So your mom tells me you also have a lot of bad dreams. Can you tell
me a little more about your bad dreams, like maybe what they’re about, how many
nights you might have them?
DEV CORDOBA: I dream a lot that I’m lost, that I can’t find my mom or my little brother.
They seem like they happen almost every night, but maybe not some nights.
DR. JENNY: Now that must feel horrible. Have you ever been lost before when maybe
you weren’t asleep?
DEV CORDOBA: Oh, no. No. And I don’t like the dark. My mom puts me in a night light
with the door open, so I know she’s really there.
DR. JENNY: That seems like that probably would help. Do you like to go to school? Or
would you rather not go?
DEV CORDOBA: I worry about by mom and brother when I’m at school. All I can think
about is what they’re doing, and if they’re OK. And besides, nobody likes me there.
They call me Mr. Smelly.
DR. JENNY: Well. That’s not nice at all. Why do you feel they call you names?
DEV CORDOBA: I don’t know. But my mom says it’s because I won’t take my baths.
[SIGHS] She tells me to, and it– and I have night accidents.
DR. JENNY: Oh, how does that make you feel?
DEV CORDOBA: Sad and really bad. They don’t know how it feels for their daddy to
never come home. What if my mom doesn’t come home too?
DR. JENNY: Yes, you seem to worry about that a lot. Does this worry stop you from
being able to learn in school?
DEV CORDOBA: Well, [SIGHS] my teacher is, all the time, telling me to sit down and
focus. And I get in trouble for [SIGHS] looking out the window. And she moved my chair
beside her desk, but I don’t mind because Billy leaves me alone now.
DR. JENNY: Billy. Have you ever hit Billy or anyone else?
DEV CORDOBA: No, but I did throw my book at him.
DR. JENNY: Hmm.
DEV CORDOBA: [CHUCKLES]
Case Study: Dev Cordoba
© 2021 Walden University, LLC 3
DR. JENNY: What about yourself? Have you ever hit yourself or thought about doing
something to hurt yourself?
DEV CORDOBA: No.
DR. JENNY: OK. Well, Dev, I would like to talk to your mom now. We’re going to work
together, and we’re going to help you feel happier, less worried, and be able to enjoy
school more. Is that OK?
DEV CORDOBA: Yes. Thank you.
MISS CORDOBA: Hi.
DR. JENNY: Thank you, Miss Cordoba, for bringing in Dev. I feel we can help him. So
tell me, what is your main concerns for Dev?
MISS CORDOBA: [SIGHS] Well, he just seems so anxious and worried all the time, silly
things like I’m going to die, or I won’t pick him up from school. He says I love his brother
more than him. He’ll throw things around the house, and gets in trouble at school for
He has a difficult time going to sleep. He wants his lights on, doors open, gets up
frequently. And he’s all the time wanting to come home from school, claims stomach
aches, and headaches almost daily. He won’t eat. He’s lost three pounds in the past
three weeks. Our pediatrician sent us to you because he doesn’t believe anything is
Oh, and I almost forgot. He still wets the bed at night. [SIGHS] We’ve tried everything.
His pediatrician did give him DDVAP, but it doesn’t seem to help.
DR. JENNY: Hmm. OK. Can you tell me, any blood relatives have any mental health or
substance use issues?
MISS CORDOBA: No, not really.
DR. JENNY: What about his father? He said that he never came home?
MISS CORDOBA: Oh, yes. His father was deployed with the military when Dev was
five. I told Dev he was on vacation. I didn’t know what to tell him. I thought he was too
young to know about war. And his father was killed, so Dev still doesn’t understand that
his father didn’t just leave him. [SIGHS] I just feel so guilty that all of this is my fault.
DR. JENNY: Miss Cordoba, you did the right thing by bringing in Dev. We can help you
Case Study: Dev Cordoba
© 2021 Walden University, LLC 4
MISS CORDOBA: Oh, thank you.
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
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
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
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.
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.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
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.).
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.
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 1 of 3
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Week (enter week #): (Enter assignment title)
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Assignment Due Date
CC (chief complaint):
Substance Current Use:
· Current Medications:
· Reproductive Hx:
Mental Status Examination:
Case Formulation and Treatment Plan:
© 2021 Walden University
Page 1 of 3
FOCUSED SOAP EVALUATION 1
FOCUSED SOAP EVALUATION 2
Focused Soap Evaluation
‘I’ve come to visit you because my mother told me that you could help me.’
He is a 7-year-old African American child who was brought to the clinic by his pediatrician and accompanied by his mother, who is in the room with him at all times He said that he is constantly nervous and that nothing calms him down. Even more disturbing, he’s been experiencing a lot of nightmares about losing his mother and sibling, and they happen virtually daily. It was reported by him that he doesn’t like to sleep in a dark room, therefore his mother always keeps the lights on and the door open to let him know she is nearby (Kodish, 2022). He confessed that he worries about his mother and brother a lot while he’s at school, and wondered if they were okay. Mr. Smelly is the name he gets at school because he doesn’t bathe and wets his bed, and this makes him feel terrible, he says.
Substance Current Use:
No illegal substances, alcohol, or cigarettes have been used by the patient.
Current Medications: Synthroid 75 mcg with Zoloft 100 mg
There is no record of rhinitis, asthma, eczema, or hives in the family.
PMHx: Vaccination for tetanus was administered on December 7, 2018.
GENERAL: Fatigue, loss of energy, lack of chills or fever
HEENT: No sneeze, no sneezing, no running nose, no hearing loss, and no sore throat from the nose, ears, and throat.
No blurred vision, no vision loss, no yellow sclerae, and no double vision are present in the eyes of the patient.
SKIN; A complete absence of rashes and itching.
CARDIOVASCULAR: No discomfort or soreness in the chest, no edema, and no palpitations were experienced.
RESPIRATORY: There is no sputum, no difficulty breathing, and no coughing in this situation.
GASTROINTESTINAL: There was no constipation, starvation, nausea, nausea, blood in the stool, or stomach problems.
GENITOURINARY: During urination, there’s no stinging or burning.
Five days ago was my last menstrual cycle.
NEUROLOGICAL: Symptoms like tingling or numbness in the limbs, dizziness or ataxia, headache, paralysis or changes in the way one manages one’s urine or bowels are absent.
MUSCULOSKELETAL: There is no stiffness or soreness in the back or joints.
HEMATOLOGIC: Brusing, hemorrhage or anemia are not present.
LYMPHATICS: No splenectomy was performed, and there were no swollen lymph nodes to speak of.
ENDOCRINOLOGIC: Temperature intolerance, sweating, fluid retention, polyuria are not present in the patient at this time.
Heart; the patient’s heart rate is 70 BPM, there are no gallops, RRR, or murmurs in the arteries.
Vitals; the patient has a 120/80 mmHg blood pressure and a fever of 100.2 degrees.
General observation: It’s safe to say that the patient is awake and aware. All questions are answered in a timely manner by him. She is in a bad mood and in a state of extreme anxiety. Stable balance and a normal walking pattern.
Skin; the skin was clear of rashes and blemishes.
Lungs; CTA on each sides
Lab: A normal TSH, CBC, and lytes.
Diagnostic results: During the assessment, it was discovered that the patient was unable to focus and maintain the attention. The findings of the other tests were all normal.
Mental Status Examination:
Young African American boy who appears to be the claimed age, is properly attired for the weather, is well-groomed, and is in good nutritional health is the subject of this investigation. There are no anomalous motor movements, yet he is cooperative with poor eye contact. Comprehensible words in the correct volume and tone with flat facial expressions are all characteristics of his demeanor at this time. It was determined that he did not have any hallucinations, delusions, or other signs of paranoia during the course of the examinations that were conducted on him (Cobham, 2020). Although he is awake and aware of the present moment, he is only vaguely aware of the nature of his disease. His memory and intellect are intact, but he is only vaguely aware of the nature of his condition.
Pediatric separation anxiety disorder
Oppositional defiant disorder
Primary diagnosis: Pediatric separation anxiety disorder
Reflections: D.C.’s diagnosis of separation anxiety disorder seems correct based on the data and mental exam. I learned that separation anxiety disorder is the most frequent child anxiety issue. In this case study, I could have built a better relationship with DC before evaluating the mother and child. Misdiagnosis, treatment compliance, conflicts of interest, and secrecy are ethical issues. Separation anxiety disorder can be averted by practicing short goodbyes, practicing leaving, avoiding rewarding fear, and keeping a familiar environment.
Case Formulation and Treatment Plan:
The goal of treating children with separation anxiety is to get them back to their usual selves (Ströhle, 2018). Therapy, medication, and relaxation techniques all play a role in treatment. As a result, D.C. will begin counseling, learn relaxation techniques, and begin taking fluoxetine 10 mg daily.
Follow up after one month of non-pharmacological therapy
The recommendation of a therapist for cognitive behavioral therapy
Recommendation of an educational group.
Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Ärzteblatt International, 115(37), 611.
Cobham, V. E., Hickling, A., Kimball, H., Thomas, H. J., Scott, J. G., & Middeldorp, C. M. (2020). Systematic review: anxiety in children and adolescents with chronic medical conditions. Journal of the American Academy of Child & Adolescent Psychiatry, 59(5), 595-618.