In this post, you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder. Review Learning Resources. Consi

NRNP 6665 WEEK 4 ASSGN: ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS

In this post you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

Review Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.

Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.

Review the video,  Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.

Consider what history would be necessary to collect from this patient.

Consider what interview questions you would need to ask this patient.

Consider patient diagnostics missing from the video: 

Provider Review outside of interview:

Temp 98.2 Pulse  90  Respiration 18   B/P  138/88

Laboratory Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H).

MAIN ASSIGNMENT: Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 

Objective: What observations did you make during the psychiatric assessment?  

Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the  DSM-5-TR diagnostic criteria for each differential diagnosis and explain what  DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.

Reflection notes: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Reading Resources

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015).  Kaplan & Sadock’s synopsis of psychiatry (11th

ed.). Wolters Kluwer.

Chapter 8, “Mood Disorders”

Zakhari, R. (2020).  The psychiatric-mental health nurse practitioner certification review manual.

Springer.

Chapter 11, “Mood Disorders”

CrashCourse. (2014, September 8).  Depressive and bipolar disorders: Crash course psychology #30 Links to an external site.  [Video]. YouTube. https://youtu.be/ZwMlHkWKDwM https://www.youtube.com/watch?v=ZwMlHkWKDwM&t=1s

Walden University. (2021).  Case study: Petunia Park. Walden University

Blackboard.  https://waldenu.instructure.com

SEE MEDICATION LISTS

Depression		Premenstrual dysphoric disorder	Seasonal affective disorder (MDD with Seasonal Variation)
agomelatine amitriptyline amoxapine aripiprazole (adjunct) brexpiprazole (adjunct)bupropion citalopram clomipramine cyamemazine desipramine desvenlafaxine dothiepindoxepin duloxetine escitalopram fluoxetine fluvoxamine iloperidone imipramine isocarboxazid ketamine lithium (adjunct) l-methylfolate (adjunct)	lofepramine maprotiline mianserin milnacipran mirtazapine moclobemide nefazodone nortriptyline paroxetine phenelzine protriptyline quetiapine (adjunct) reboxetine selegiline sertindole sertraline sulpiride tianeptine tranylcypromine trazodone trimipramine venlafaxine vilazodone vortioxetine	citalopram desvenlafaxine duloxetin eescitalopram fluoxetin eparoxetine pepexev sarafe, sertraline venlafaxine	Bupropion HCL extended-release

 

Bipolar depression	Bipolar disorder (mixed Mania/Depression	Bipolar maintenance	Mania
lithium (used with lurasidone) lurasidone olanzapine-fluoxetine combination (symbyax) quetiapine valproate (divalproex) (used with lurasidone)	aripiprazole asenapine carbamazepine	olanzapine ziprasidone	aripiprazole lamotrigine lithium olanzapine	aripiprazole asenapine carbamazepine lithium olanzapine quetiapine risperidone valproate (divalproex) ziprasidone

,

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

,[removed],

[MUSIC PLAYING] DR. MOORE: Hi. Good afternoon. My name is Dr. Moore. Am I understanding you're here for a mental health assessment today? PETUNIA PARK: That's right. DR. MOORE: OK. So to make sure I have the right patient and the right chart, can you tell me your name and your date of birth? PETUNIA PARK: Yes. I'm Petunia Park. My birthday is July 1, 1995. DR. MOORE: And can you tell me what today's date is? PETUNIA PARK: So it's December 1. DR. MOORE: Do you know the year? PETUNIA PARK: 2020. DR. MOORE: And what day of the week is this? PETUNIA PARK: It's Tuesday. [CHUCKLING] DR. MOORE: And do you know where we are today? PETUNIA PARK: Yes I am here in the beautiful, sunny office at the clinic. DR. MOORE: OK, great. Thank you. So can you tell me a little bit about why you're here today? What brings you here today? PETUNIA PARK: Yes. So I have a history of taking medications and then stopping them. I don't think I need them. I really feel like the medication squashes who I am. DR. MOORE: OK, OK. So I'm going to be able to help you with that. But to begin, I'm going to ask you some questions about your family. I'm going to ask you some history-type questions. I'm going to ask you some symptoms that you might be having. And all of these questions are going to help me work with you on a treatment plan, OK? So I would like to begin with, when was the first time that you ever had any mental health or substance use treatment in your life? PETUNIA PARK: OK. Well, when I was a teenager, my mom put me in the hospital after I went four or five days without sleeping. I think I may have been hearing things at that time. [CHUCKLES] I think they started me on some medication, but I'm not sure. DR. MOORE: Oh, OK so you were hospitalized. How many times have you been hospitalized for mental health? PETUNIA PARK: Oh, I've been hospitalized about four times. The last time was this past spring. No detox or residential rehabs, though. DR. MOORE: OK, good. Were any of these hospitalizations due to any suicide gestures? PETUNIA PARK: One was in 2017. I overdosed on Benadryl, but I've not had those thoughts since then. DR. MOORE: Well, I'm very glad to hear that you've not had any of those thoughts since then. And I'm glad that you turned out OK from that overdose. I'm glad that you're here today. Can you tell me a little bit about what you've been diagnosed with during your past treatments? PETUNIA PARK: Well, I think depression, and anxiety, had some even say maybe bipolar. DR. MOORE: OK, and what medications have you been tried on before for those illnesses? And if you can remember, what was your reactions to those medications? PETUNIA PARK: Oh, let's see. Oh, I took Zoloft, and that made me feel really high. [CHUCKLES] I couldn't sleep. My mind was racing, and then I took risperidone. That made me gain a bunch of weight. Seroquel gave me weight, too. I took Klonopin, and that seems to slow me down some. I really can't remember the others. I think the one I just stopped taking was helping. It started with an L, I think. I don't really remember the name, but it squashed me in creativity. DR. MOORE: OK, well, we're going to try to help you find some medication that doesn't make you feel squashed or have any of those negative side effects today. But in order to do that, I need some more information. And the next questions I'm going to ask you are about substances you may have used. And I want you to know that you don't get in trouble in here if you've used some of these substances. It really just helps me to make sure that what's in your system that could be impacting your neurochemistry. And when we do talk about medications, so I don't give you something that would negatively interact with something you may be using, OK? So do you– PETUNIA PARK: OK. DR. MOORE: –use any nicotine? PETUNIA PARK: Yes. I smoke about a pack a day, and I'm not going to quit for you, either. [CHUCKLES] Oh. DR. MOORE: That's OK, that's OK. And what about alcohol? When was your last drink of alcohol? PETUNIA PARK: When I was 19 because alcohol and me do not work well together. [CHUCKLES] DR. MOORE: OK, and what about any marijuana? When was your last use of any marijuana? PETUNIA PARK: Oh no. I tried that once and got really paranoid. DR. MOORE: OK. What about any last use of cocaine? PETUNIA PARK: Never. DR. MOORE: Last use of any stimulants or methamphetamines? PETUNIA PARK: Never. DR. MOORE: What about any huffing or inhalants? PETUNIA PARK: Never. DR. MOORE: OK, have you used anything like Klonopin or Xanax, any of those sedative medications? PETUNIA PARK: Never. DR. MOORE: All right, good. What about any hallucinogenics like LSD, or PCP, or mushrooms? PETUNIA PARK: No, never. DR. MOORE: Wonderful. OK, what about any use of pain pills or opiate medications? Anything prescribed or anything you've obtained from the street? PETUNIA PARK: No, never. DR. MOORE: Good. And anything synthetic like Spice, or ecstasy, Bath Salts, Mollies, anything like that? PETUNIA PARK: Never. DR. MOORE: Oh, wonderful. Well, I'm glad to hear that. You know those things aren't good for your brain. So I encourage you to continue to stay away from those things. Have you ever had any blackouts or seizures from drugs or alcohol? Or seen things that you weren't sure were there? PETUNIA PARK: Never. DR. MOORE: Good. What about any legal issues or any DUIs? PETUNIA PARK: Never. DR. MOORE: OK. Good, good. All right, so I'm just going to ask a little bit about your family right now. Any blood relatives have any mental health or substance abuse issues? PETUNIA PARK: Yeah, well, well, why would you ask that? It's not your business. DR. MOORE: Right. I could see where you might find that wouldn't be any my business. But really, sometimes these issues can be genetic. They're alarm behaviors. So my understanding of your family helps me to understand you. PETUNIA PARK: Huh. Well, my mother was seen as crazy. I think they said she had bipolar or something. And my father went to prison for drugs. And well, we haven't heard, or seen, or heard from him in 8 or 10 years. My brother, while I think he's a little schizo, but he hasn't ever went to the doctor. Nobody else with anything. DR. MOORE: OK. So that sounds like it must be tough growing up not seeing your father and having some of those issues in your family. But any family, blood relatives commit suicide? PETUNIA PARK: Well, my mom tried, but nobody really did it, you know? DR. MOORE: OK. Have you ever done anything like that, or anything like cut on yourself, burn yourself? PETUNIA PARK: I already told you, I tried to kill myself. Why ask me that again? No, I'm not going to kill myself or anyone else, and I don't cut myself. DR. MOORE: OK. Well, I'm glad to hear that. And I want you to know that I am here for you, and we most certainly will make sure you have a crisis like number at the end of this session if you do have those thoughts in the future. So I'm glad to hear that you don't have those thoughts today. OK. What type of medical issues do you have? PETUNIA PARK: Oh, hoo. Let's see. I have a thyroid issue that I take some medicine for, that hypothyroidism. And I take a birth control pill for polycystic ovaries. DR. MOORE: OK, when was your last menses? PETUNIA PARK: Oh, well I have a regular one each month. So let's see. I

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