Focused soap note for anxiety, ptsd, and ocd

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 In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches.  

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 1 of 3

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Content

Name: NRNP_6675_Week3_Assignment_Rubric

  Excellent

90%–100%

Good

80%–89%

Fair

70%–79%

Poor

0%–69%

Create documentation in the Focused SOAP Note Template about your assigned patient.

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

Points:

Points Range:
14 (14%) – 15 (15%)

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

Feedback:

Points:

Points Range:
12 (12%) – 13 (13%)

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

Feedback:

Points:

Points Range:
11 (11%) – 11 (11%)

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

Feedback:

Points:

Points Range:
0 (0%) – 10 (10%)

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.

Feedback:

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

Points:

Points Range:
14 (14%) – 15 (15%)

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

Feedback:

Points:

Points Range:
12 (12%) – 13 (13%)

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

Feedback:

Points:

Points Range:
11 (11%) – 11 (11%)

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

Feedback:

Points:

Points Range:
0 (0%) – 10 (10%)

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.

Feedback:

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form

• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Points:

Points Range:
18 (18%) – 20 (20%)

The response thoroughly and accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

Feedback:

Points:

Points Range:
16 (16%) – 17 (17%)

The response accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.

Feedback:

Points:

Points Range:
14 (14%) – 15 (15%)

The response documents the results of the mental status exam with some vagueness or innacuracy.

Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.

Feedback:

Points:

Points Range:
0 (0%) – 13 (13%)

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.

Feedback:

In the Plan section, provide:

• Your plan for psychotherapy

• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

• Incorporate one health promotion activity and one patient education strategy.

Points:

Points Range:
23 (23%) – 25 (25%)

The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient.

The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding.

The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.

Feedback:

Points:

Points Range:
20 (20%) – 22 (22%)

The response provides an evidence-based and appropriate plan for psychotherapy for the patient.

The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided.

The response includes at least one health promotion activity and one patient education strategy.

Feedback:

Points:

Points Range:
18 (18%) – 19 (19%)

The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient.

The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general.

The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.

Feedback:

Points:

Points Range:
0 (0%) – 17 (17%)

The response provides an incomplete or inaccurate plan for psychotherapy for the patient.

The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing.

The health promotion and patient education strategies are incomplete or missing.

Feedback:

• 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!), 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.).

Points:

Points Range:
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

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

Points:

Points Range:
9 (9%) – 10 (10%)

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

Feedback:

Points:

Points Range:
8 (8%) – 8 (8%)

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

Feedback:

Points:

Points Range:
7 (7%) – 7 (7%)

Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

Feedback:

Points:

Points Range:
0 (0%) – 6 (6%)

Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

Feedback:

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

Points:

Points Range:
5 (5%) – 5 (5%)

Uses correct APA format with no errors

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Contains 1-2 grammar, spelling, and punctuation errors

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 grammar, spelling, and punctuation errors

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Feedback:

Written Expression and Formatting – English Writing Standards:

Correct grammar, mechanics, and punctuation

Points:

Points Range:
5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors

Feedback:

Points:

Points Range:
4 (4%) – 4 (4%)

Contains 1-2 APA format errors

Feedback:

Points:

Points Range:
3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 APA format errors

Feedback:

Points:

Points Range:
0 (0%) – 3 (3%)

Contains five or more APA format errors

Feedback:

Show Descriptions

Show Feedback

Create documentation in the Focused SOAP Note Template about your assigned patient.

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

Levels of Achievement:

Excellent

90%–100%
14 (14%) – 15 (15%)

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

Good

80%–89%
12 (12%) – 13 (13%)

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

Fair

70%–79%
11 (11%) – 11 (11%)

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

Poor

0%–69%
0 (0%) – 10 (10%)

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis. Or the subjective documentation is missing.

Feedback:

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

Levels of Achievement:

Excellent

90%–100%
14 (14%) – 15 (15%)

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

Good

80%–89%
12 (12%) – 13 (13%)

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

Fair

70%–79%
11 (11%) – 11 (11%)

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

Poor

0%–69%
0 (0%) – 10 (10%)

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.

Feedback:

In the Assessment section, provide:

• Results of the mental status examination, presented in paragraph form

• At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Levels of Achievement:

Excellent

90%–100%
18 (18%) – 20 (20%)

The response thoroughly and accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.

Good

80%–89%
16 (16%) – 17 (17%)

The response accurately documents the results of the mental status exam.

Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.

Fair

70%–79%
14 (14%) – 15 (15%)

The response documents the results of the mental status exam with some vagueness or innacuracy.

Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.

Poor

0%–69%
0 (0%) – 13 (13%)

The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.

Feedback:

In the Plan section, provide:

• Your plan for psychotherapy

• Your plan for treatment and management, including alternative therapies. Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

• Incorporate one health promotion activity and one patient education strategy.

Levels of Achievement:

Excellent

90%–100%
23 (23%) – 25 (25%)

The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient.

The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding.

The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.

Good

80%–89%
20 (20%) – 22 (22%)

The response provides an evidence-based and appropriate plan for psychotherapy for the patient.

The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided.

The response includes at least one health promotion activity and one patient education strategy.

Fair

70%–79%
18 (18%) – 19 (19%)

The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient.

The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general.

The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.

Poor

0%–69%
0 (0%) – 17 (17%)

The response provides an incomplete or inaccurate plan for psychotherapy for the patient.

The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing.

The health promotion and patient education strategies are incomplete or missing.

Feedback:

• 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!), 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.).–

Levels of Achievement:

Excellent

90%–100%
5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Good

80%–89%
4 (4%) – 4 (4%)

Reflections demonstrate critical thinking.

Fair

70%–79%
3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking.

Poor

0%–69%
0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing.

Feedback:

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

Levels of Achievement:

Excellent

90%–100%
9 (9%) – 10 (10%)

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

Good

80%–89%
8 (8%) – 8 (8%)

The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.

Fair

70%–79%
7 (7%) – 7 (7%)

Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.

Poor

0%–69%
0 (0%) – 6 (6%)

Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.

Feedback:

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

Levels of Achievement:

Excellent

90%–100%
5 (5%) – 5 (5%)

Uses correct APA format with no errors

Good

80%–89%
4 (4%) – 4 (4%)

Contains 1-2 grammar, spelling, and punctuation errors

Fair

70%–79%
3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 grammar, spelling, and punctuation errors

Poor

0%–69%
0 (0%) – 3 (3%)

Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding

Feedback:

Written Expression and Formatting – English Writing Standards:

Correct grammar, mechanics, and punctuation

Levels of Achievement:

Excellent

90%–100%
5 (5%) – 5 (5%)

Uses correct grammar, spelling, and punctuation with no errors

Good

80%–89%
4 (4%) – 4 (4%)

Contains 1-2 APA format errors

Fair

70%–79%
3.5 (3.5%) – 3.5 (3.5%)

Contains 3-4 APA format errors

Poor

0%–69%
0 (0%) – 3 (3%)

Contains five or more APA format errors

Feedback:

Total Points: 100

Name: NRNP_6675_Week3_Assignment_Rubric

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 6675: PMHNP Care Across the Lifespan II

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 1 of 3

Case Study: Dev Cordoba

© 2021 Walden University, LLC 1

Case Study: Dev Cordoba
Program Transcript

[MUSIC PLAYING]

DR. JENNY: Hi there. My name is Dr. Jenny. Can you tell me your name and how old

you are?

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

happy?

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

throwing things.

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

physically wrong.

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

with him.

Case Study: Dev Cordoba

© 2021 Walden University, LLC 4

MISS CORDOBA: Oh, thank you.

[MUSIC PLAYING]

Week 9: Focused SOAP Note and Patient Case

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Faculty Name

Assignment Due Date

Week 9: Focused SOAP Note and Patient Case

Subjective:

CC (chief complaint): “I’m seeking a psychiatrist because my primary care physician suggested for me to see a psychiatrist to help me with my anger issues.”

HPI: The patient is a 21-year-old African American female who was seen in the clinic for her initial evaluation via telehealth session with her consent obtained. The patient stated that she was seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her with anger issues. She stated that she has not being diagnosed for any mental problem before and has never been on any medication before as well. The patient stated that she gets very angry, depressed, and anxious quickly; even she reported that sometimes she would lash out on people without any reason. She said that her siblings get on her nerves sometimes and she gets irritated especially when they are together for so a long period of time. She stated, “I just had my birthday, and I went out for a dinner with my friends, and I had a good time”. The patient reported, “I hear voices, but not that type of crazy voices that tell you to do somethings”. “It is just from my inner thought, maybe thinking in my head and talking out loud to myself”. She said she just gets irritated here and there from some people. She denies suicidal or homicidal ideation or intent presently. She also denies delusional or hallucination presently.

Substance Current Use: None

Family History: Maternal grandmother has depression and dementia.

Psychosocial History: The patient stated that she grew up with both parents but now they are divorced. She now lives with her mother and her siblings. She reported doing good and working two jobs to support herself. She said that she works as a pharmacy technician Monday through Friday and works as a concierge on weekends.

She completed high school and graduated. She has few friends and she is not in any relationship right now. She is not married and has no children.

Medical History: None

· Current Medications: None.

· Allergies: NKDA

· Reproductive Hx: Heterosexual. Currently not sexually active. No children.

ROS:

· GENERAL: Reports poor eating habits. Denies weakness, fatigue, fever, or chills.

· 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: No 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:

Vital signs: B/P: 128/66/ Temp. 97.3, Pulse 74, Respiration: 18, Oxygen saturation: 98%

Height: 5’4’’

Weight: 200lbs

Diagnostic results: PHQ-9 15/27. Signifies moderately severe depression.

Assessment:

Mental Status Examination: The patient is alert and oriented x 4 to person, place, time, and the situation. The patient was seen today in the clinic for initial evaluation via telehealth. The patient appeared very clean and dressed neatly. She has normal eye contact with normal psychomotor activity. Her attention is intact and very cooperative. Her speech is normal, her thought process is goal-directed, and her thought contents are circumstantial. Perceptions, insight, and judgment are good, intact cognitive, and language is normal and appropriate. She has euthymic and euphoric moods, and the affect is congruent to her mood. Memory intact, she denies suicidal or homicidal ideation or intent. She denies delusions and hallucinations.

Diagnostic Impression/Diagnostic Differential:

1). Schizoaffective Disorder (with anxiety)

Based on the information provided in the patient case, schizoaffective disorder is highly likely to be the primary diagnosis. To be diagnosed with this condition, the patient must meet the primary criteria (criterion A) for schizophrenia that includes at least two of hallucinations, delusions, disorganized speech, negative symptoms, and grossly disorganized or catatonic behavior (Baryshnikov et al., 2020). The patient must also present with a major mood episode, either depression or mania, lasting for uninterrupted period of time and accompanied with either delusions or hallucinations. Furthermore, the symptoms should not be caused by substance use (Baryshnikov et al., 2020).

In the patient’s case, she meets criterion A for schizophrenia because she presents with auditory hallucinations where she hears voices in her head and starts talking out loud to herself. Also, she presents with negative symptoms because she reports to be depressed. Furthermore, the patient’s symptoms are not caused by substance abuse which is characteristic of schizoaffective disorder (Das-Munshi et al., 2018). The patient also presents with a high degree of irritability which is a common characteristic in patients with schizoaffective and bipolar disorders. This condition presents various behavioral symptoms such as angry outbursts where patients can suddenly erupt in anger, just like it is reported in the patient’s case (Das-Munshi et al., 2018).. Therefore, all this information points to schizoaffective disorder as the primary diagnosis. Anxiety is exhibited by her reports of feeling extremely anxious even for no real reason. Anxiety is a common co-occurring factor with schizoaffective disorder.

2). Schizophrenia

This is also another likely diagnosis for the patient. The condition is highly related to schizoaffective disorder and one may be confused with the other (Holt et al., 2018). The diagnosis is considered because the patient presents with auditory hallucinations and negative symptoms, such as depressed moods. She also presents with irritability yet agitation and irritability are commonly observed among patients with schizophrenia. However, the diagnosis is ruled out because with schizophrenia, the patients cannot tell the difference between reality and fiction during delusions or hallucinations. However, the patient in this case is able to tell the difference between reality and the voices that she has in her head which is usually observed in patients with schizoaffective disorder (Strik et al., 2017). Furthermore, the mood disorder in this patient is front and center yet with schizophrenia, it is usually not a dominant part of the disorder. Finally, the diagnosis is also ruled out because there is no evidence that the condition disrupts either her ability to work or her relationships, which would signify schizophrenia.

3). Generalized anxiety disorder

The diagnosis is considered because the patient admits that she experiences excessive anxiety without any real reason most of the time. The patient also presents with irritability which may or may not be observable among patients with generalized anxiety disorder (Xu et al., 2021). She also reports that she has poor eating habits which is usually a common characteristic of generalized anxiety disorder. However, this diagnosis is ruled out because other hallmark criteria are not met since there is no evidence that the patient’s worry occurs more than not for at least six months; it is not reported that the worry is very challenging to control for the patient; and the worry does not cause bad concentration or restlessness in the case of the patient (Xu et al., 2021).

Reflections:

Recording comprehensive information to be utilized during the assessment and the development of the most likely diagnosis for the patient is important, especially when the patient is presenting with symptoms of schizoaffective disorders. Upholding ethical guidelines can be accomplished by ensuring that the patient has autonomy of her care and that she is educated about her diagnosis. What I could do differently would be to obtain more information about the patient’s family history to assess the risk of mental illness. It would also be important to make sure that the patient consents to treatment before beginning the plan.

Case Formulation and Treatment Plan: 

The patient is a 21-year-old African American female who stated that she was seeking a psychiatrist because her primary care physician suggested for her to see a psychiatrist to help her with anger issues. She stated that she has not being diagnosed for any mental problem before and not on any medication. The patient stated that she gets angry very quickly, depressed, and very anxious, sometimes would lash out on people without any reason. She also reported auditory hallucinations. The primary diagnosis is schizoaffective disorder. The patient is referred to a psychotherapist and will be scheduled to see a therapist weekly. The patient is encouraged to engage in exercise to build up her serotonin. She is also encouraged to be taking deep breathing, not to eat after 7 pm, and keep electronics away at bedtime. Also, she encouraged to keep a journal of her daily activities and will review it next appointment in 4 weeks. She is encouraged to call 911 for suicidal or homicidal ieation or intent. She is also encouraged to call the psychiatrist’s office whenever she wants to talk. She verbalized understanding.

Plan of Care:

The patient will have decreased feelings of depression and anxiety over the next 90 days.

The patient is educated on the use of positive coping skills like exercising, deep breathing, and journaling daily.

The patient is referred to a psychotherapist weekly.

Follow up in 4 weeks.

Call 911 for suicidal or homicidal ideation or intent.

Conclusion

Schizoaffective disorder is very difficult to diagnose due to its complicated symptoms. Therefore, providers must obtain comprehensive information about the patient’s case to correctly determine the primary diagnosis of the condition. Providers should also use critical thinking when making the differences between schizoaffective and schizophrenia disorders.

References

Baryshnikov, I., Sund, R., Marttunen, M., Svirskis, T., Partonen, T., Pirkola, S., & Isometsä, E. T. (2020). Diagnostic conversion from unipolar depression to bipolar disorder, schizophrenia, or schizoaffective disorder: A nationwide prospective 15‐year register study on 43 495 inpatients. Bipolar disorders22(6), 582-592.

Das-Munshi, J., Bhugra, D., & Crawford, M. J. (2018). Ethnic minority inequalities in access to treatments for schizophrenia and schizoaffective disorders: findings from a nationally representative cross-sectional study. BMC medicine16(1), 1-10.

Holt, R. I., Hind, D., Gossage-Worrall, R., Bradburn, M. J., Saxon, D., McCrone, P., … & Northern, A. (2018). Structured lifestyle education to support weight loss for people with schizophrenia, schizoaffective disorder and first episode psychosis: the STEPWISE RCT. Health Technology Assessment (Winchester, England)22(65), 1.

Strik, W., Stegmayer, K., Walther, S., & Dierks, T. (2017). Systems neuroscience of psychosis: mapping schizophrenia symptoms onto brain systems. Neuropsychobiology75(3), 100-116.

Xu, X., Dai, J., Chen, Y., Liu, C., Xin, F., Zhou, X., … & Becker, B. (2021). Intrinsic connectivity of the prefrontal cortex and striato-limbic system respectively differentiate major depressive from generalized anxiety disorder. Neuropsychopharmacology46(4), 791-798.

© 2021 Walden University

Page 1 of 3

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 6675: PMHNP Care Across the Lifespan II

Faculty Name

Assignment Due Date

Introduction

Information from a patient’s first appointment is used to plan each psychological intervention Refai et al (2018). Each patient’s treatment starts with a full health and mental health exam that includes talking openly and honestly about mental health, drug use, and the mental health history of their family. In this case, the patient’s test was written down, and the diagnostic idea was made based on what was learned from the patient during the trial. As the situation got worse, solutions were made. The patient, a 7 year old boy, was scheduled for a psychiatric exam after the pediatrician suggested he see a psychiatrist. At this time, the patient is not taking any medicine. The patient was initialy placed on DDAVP by his pediatrician which did not help.

Subjective:

CC: “My mother told me you will help me get better”

HPI: R.C. is a 7-year-old boy who was referred to a psychiatrist for a checkup after his teacher tried unsuccessfully to help him with his mood. During the interview, the mother and patient stated that a pediatrician put her son on DDAVP, which did not help him. During the chat, the patient expresses that he occasionally feels anxious. “Most of the time I feel anxious, but I don’t know, just everything,” the patient explained. The patient also confesses to having nightmares. “I regularly dream about getting lost, I can’t find my mother or my small brother,” he stated, which is terrible. It appears that a dream occurs virtually every night, although perhaps not every night.

The patient has a nightmare and cannot find his sibling or mother. When questioned if the patient is feeling disoriented. “When I’m alone,” the patient says, “I worry about my mother and brother.” “People at school don’t like me,” the patient continued. According to the patient’s mother, her classmates nicknamed her nasty things because she didn’t wash her hands. The patient expressed his displeasure with it. His mother never returned home. The patient claimed that his teacher was also spoiling him in class. His teacher instructed him to sit down and focus. The patient’s mother was also interviewed throughout the session.

The mother voiced her concern that the patient was frightened and worried about silly things like dying, that her mother loved her brother more than him, and that she would not pick him up from school. The mother also mentioned that the patient’s father had been killed in combat, but that it was too soon to tell him because he was too young. My mother feels bad about not exposing Rev.’s father and blames herself for the pastor’s behavior. During the interview, Mom revealed that the patient was soaking the bed at night, that the pediatrician sent them to a Psychiatrist and prescribed DDVAP, but that the drug did not appear to help. The mother reported that the patient had trouble sleeping, reading, getting into trouble at school, flung things around the house, wanted her light on at night with the doors open, had trouble sleeping, and claimed to have a stomach ache. They are practically everyday sent home from school.

Substance Current Use: No use of any substance

Medical History:

· Current Medications: No current prescribed medication. Patient was once placed on DDAVP

· Allergies: Seasonal allergies

· Reproductive Hx: patient denies any sexual abuse

ROS:

· GENERAL: No physical pain was reported during the trial, but the person had a history of arthritis, fibromyalgia, diabetes, and diabetic neuropathy. She ended up in a clinic by herself, and there were no reports of psychomotor problems.

· HEENT: No vision problem

· SKIN: Denies any skin lesions.

· CARDIOVASCULAR: Denies any chest discomfort, pain, or chest tightness.

· RESPIRATORY: No reports of respiratory discomfort, no coughing, wheezing, and shortness of breath.

· GASTROINTESTINAL: Denies any stomach discomfort

· GENITOURINARY: Denies pain, burning, or discharge on urination and reports no flank pain.

· NEUROLOGICAL: Denies headache, dizziness, syncope, tingling, numbness, and lightheadedness

· MUSCULOSKELETAL: Denies muscle pain, muscle weakness, swelling, joint pain, and back pain.

· HEMATOLOGIC: Denies bleeding, bruising, or anemia.

· LYMPHATICS: No reports of enlarged lymph nodes and no history of splenectomy

· ENDOCRINOLOGIC: Denies cold or heat intolerance, no excessive sweating, no reports of chills, polyuria, polydipsia, and urinary frequency

Objective:

Diagnostic results:

PHQ 9 : SCORED 13

GAD 7 : SCORED 10

Assessment:

The client is awake and able to understand; he is calm, helpful, and aware. He is clean, neat, and dressed for the weather. The client’s speech is clear, consistent, and loud and good in a general way. Strong language skills and a logical, goal-oriented way of thinking. He hasn’t shown any signs of mental illness, like lying, deception, strange behavior, or promiscuity. Patient was cooperative, not fidgeting, makes good eye contact and able to sit still. Patient appears to be anxious and worried Affect was full range, somewhat constricted and often sad. Able to stay still. No abnormal movement noted. Gait steady and posture upright. Patient was coherent but not very logical due to worry. No acute psychosis or mood symptoms.

Differential Diagnosis:

Generalized Anxiety Disorder: Common anxiety disorder is a mental health issue that primarily affects children and teenagers Strawn et al., (2018). A young boy suffering from a common anxiety disorder feels intense worry and panic for no apparent reason. Physical appearance, previous habits, social acceptance, family troubles, failure to fulfill parental standards, personal abilities, and academic accomplishment are all frequent worries for children and adolescents suffering from common anxiety disorders. Generalized Anxiety Disorder can warn us of potential threats and assist us in planning and paying attention.

Anxiety disorders are the most common type of mental illness, affecting approximately one-third of all adults at some point in their lives. DSM-5 Diagnostic Conditions for Generalized Anxiety Disorder: Excessive anxiety and worry about the number of events or activities that occur more than six days in a row (such as work or schoolwork), a person having difficulties controlling their anxiety, and three of the six symptoms listed below are related to anxiety and anxiety: Excessive weariness, difficulty concentrating, or having your thoughts wander are all signs of restlessness. Irritability, muscle stiffness, and difficulty sleeping are all symptoms of anger.

Dysthymic Disorder: According to Strawn et al., (2018), disorders are not the result of direct physical consequences or a general health condition. Presence when suffering from two or more of the following; Overeating or hypersomnia, low energy or weariness, low self-esteem, decreased focus or difficulties making decisions, feelings of hopelessness are all symptoms of anorexia nervosa. Symptoms create severe clinical depression or incapacity in crucial professional areas. Although dysthymia was once regarded to be less severe than major depression, its consequences are now universally acknowledged to be severe, including significant functional impairment, increased morbidity, and an increased risk of suicide. The DSM-5 provides the following possibilities for diagnosing Dysthymic Disorder. A person should experience five or more symptoms within two years, at least one of which should be (1) bitterness or (2) a lack of interest or pleasure. -DSM-5 lists changes in energy levels, stress levels most of the day, practically everyday, decreased or increased appetite almost daily, self-esteem, anxiety, isolation, diet change, forgetfulness, not finishing responsibilities at work or school, guilt, and loss of energy.

Adjustment Disorder: Adjustment disorder, according to Maercker and Lorenz (2018), is a negative response to perceived stress or lifestyle changes that is characterized by a strong emphasis on stress and difficulty to adapt. And disorders are defined as the occurrence of emotional or behavioral problems as a result of stress. Correction can result from unexpected or unexpected circumstances, leading a person to feel confused, apprehensive, anxious, and disturbed, preventing the patient from returning to his normal routine. Breakups, marriage breakdowns, the end of a long-term relationship, the untimely death of a loved one, job loss, and the possibility of sexual abuse are all stressful circumstances that can lead to correction.

Reflections:

The combination of medication and therapy will help reduce the symptoms of Major Dysthymic Disorder, Generalized Anxiety Disorder, and adjustment Disorder Freire et al., (2020). It has been shown that combining psychotherapy with medication is a good way to treat anxiety and depression, especially if the symptoms are not caused by the medication or by other health problems. This client is encouraged to keep going to his or her regular therapy sessions because it will help him or her build on or come up with ways to deal with pressures now and in the future. When combined with psychopharmacology, mental-behavioral therapy is the best way to treat a lot of mental health problems. The client was told to follow his primary care doctor’s orders to do all of the necessary physical exercises, such as getting lab and imaging tests when needed.

One thing I could have done differently as a PMHNP is to meet the patient first to develop a therapeutic relationship, then address questions unrelated to scheduled sessions to assist build acceptance. the environment Without looking biased, ask open-ended inquiries about the patient’s personality, disease, or personality. Inquire about the patient’s sexual orientation and preferred mode of communication. Trust, respect for diversity, respect for religion, equality, fairness, and social justice are all characteristics of cultural suitability that should be considered during any interview or encounter between a health practitioner and a patient. When I talk to a patient about their symptoms of mental illness, I look at the way they look, talk, and act to see if there are any clues that can explain their symptoms.

Case Formulation and Treatment Plan:

Medication and speech therapy were used to treat the patient. Psychotherapy will assist the client in changing their feelings and behaviors. The patient’s mother will be given an instruction booklet, as well as tasks and follow-up consultations on topics related to healing and coping. Bed-wetting can be avoided by reducing the quantity of alcohol a child drinks in the evening, avoiding caffeinated meals and beverages, and encouraging regular bathroom usage during the day, according to Gronemann et al., (2021). The mother was instructed to wake the patient up at night to urinate and to change the patient’s clothes before going to school in the morning. The patient should be given personal hygiene treatment. In the event of an emergency, the provider gave the patient two phone numbers to call: 911 emergency and the Customer Problem Line. Doctors’ and clinicians’ reports were evaluated for comprehension, cooperation, and continuity of care. If the patient’s mother had any questions or worries regarding the development of any unpleasant or unexpected side effects, she was instructed and urged to contact their primary care physician or the nearest emergency facility.

Conclusion

During the interview, the PMHNP student should try to give the patient his or her own facts or information so that he or she can give the right personal or personal care, even though the supervisor has already given the student information about the patient. PMHNP should avoid Avoid discrimination based on the patient’s personality, health, or what the doctor says about the patient. Also, ask the patient if they’d like to talk privately if they have something they’d like to share with you in private. Then, find out about the patient’s stress, depression, identity, and sexual orientation. It is also important to know what makes one mental state different from another.

References

Freire, R. C., Cabrera-Abreu, C., & Milev, R. (2020). Neurostimulation in anxiety disorders, post-traumatic stress disorder, and obsessive-compulsive disorder. Anxiety Disorders, 331-346.

Gronemann, F. H., Petersen, J., Alulis, S., Jensen, K. J., Riise, J., Ankarfeldt, M. Z., … & Osler, M. (2021). Treatment patterns in patients with treatment-resistant depression in Danish patients with major depressive disorder. Journal of Affective Disorders287, 204-213.

Maercker, A., & Lorenz, L. (2018). Adjustment disorder diagnosis: Improving clinical utility. The World Journal of Biological Psychiatry19(sup1), S3-S13.

Refai, M., Andolfi, M., Gentili, P., Pelusi, G., Manzotti, F., & Sabbatini, A. (2018). Enhanced recovery after thoracic surgery: patient information and care-plans. Journal of thoracic disease10(Suppl 4), S512.

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 pharmacotherapy19(10), 1057-1070.

© 2021 Walden University

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