Assignment 2: Week 2 Focused SOAP Note and Patient Case Presentation/NRN/PPRAC 6665

Assignment 2: Focused SOAP Note and Patient Case Presentation

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Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

To Prepare
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.

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Please Note:
All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Ensure that you have the appropriate lighting and equipment to record the presentation.
The Assignment
Record yourself presenting the complex case for your clinical patient.

Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.

In your presentation:

Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., donâ€™t use the patientâ€™s name or any other identifying information).
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and â€œnormalâ€ (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patientâ€™s symptoms.
Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.

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Week 2: Focused SOAP Note and Patient Case Presentation

Subjective:

CC (chief complaint): “My moods keep on changing.”

HPI:

D.S is a 42-year-old Caucasian male client who presented to the psychiatric clinic with reports of having constantly changing moods. The client reported having a severely elevated mood, alternating with profound low mood episodes. He mentioned that for some weeks, he is usually in a very excited mood, feels like he can conquer anything, and engages in many activities. During the ‘happy’ episodes, he gets creative and does a lot of painting work. Besides, he rarely eats adequate food since eating takes much time that could be spent on his painting work. He also sleeps minimally, about 3-4 hours per day, and thinks sleeping more than that is wasting time he could have used to do more paintings. Although the client engages in much painting, he rarely finishes one painting before starting another, ending in a ton of half-done paintings.

The client reports that the happy episode suddenly ends, and he gets into a low mood where he loses interest in painting. He perceives that this is caused by fatigue and lack of adequate sleep. During the low moods, he has an increased appetite which often leads to gaining some pounds. He also sleeps a lot, 10-12 hours, and feels sleepy during the day and fatigued most of the time. The depressed mood episodes last 4-6 weeks, and his mood then switches to an excited one for almost a similar period.

Substance Current Use: Takes 3-4 beers daily in depressed episodes. Smokes 1PPD. Denies illicit drug use.

Medical History:

Current Medications: None
Allergies: None

Reproductive Hx: None

ROS:

GENERAL: Reports weight gain and hypersomnia during depressive episodes. Negative for fever, chills, malaise, or fatigue.
HEENT: Denies eye pain, vision changes, blurred/double vision, ear pain, hearing loss, sneezing, or sore throat.
SKIN: Denies bruises, rashes, or discolorations.
CARDIOVASCULAR: Denies chest pain, SOB, palpitations, or edema.
RESPIRATORY: Denies breathing difficulties, cough, or wheezing.
GASTROINTESTINAL: Reports increased appetite during the depression. Negative for epigastric pain, abdominal pain, nausea/vomiting, or bowel changes.
GENITOURINARY: Denies dysuria or increased frequency/urgency.
NEUROLOGICAL: Denies dizziness, muscle weakness, headaches, or loss of consciousness.
MUSCULOSKELETAL: Denies muscle pain or joint pain/stiffness.
HEMATOLOGIC: Denies delayed wound healing.
LYMPHATICS: Negative for swelling of lymph nodes.
ENDOCRINOLOGIC: Negative for heat/cold intolerance, excessive thirst, hunger, or urine production.

Objective:

Diagnostic results: No tests requested.

Assessment:

Mental Status Examination:

The client is well-groomed but inappropriately dressed for the weather (he wears a rain jacket and winter beanie during summer). He is alert and oriented but restless and distracted. The self-reported mood is excited, and the affect is expansive. The client is very talkative with a high volume and rate of speech. He demonstrates an incoherent and illogical thought process with pressure of speech. He exhibits delusions of grandeur with an elevated sense of self-worth. Hallucinations are absent, and he denies suicidal or homicidal thoughts or ideas. His recent and long-term memory is intact. He demonstrates impaired judgment, and insight is lacking.

Diagnostic Impression:

Bipolar Disorder: Bipolar disorder presents with manic and depressive episodes, which usually alternate, although most individuals have a predominance of one or the other (O’Donovan & Alda, 2020). A manic episode is described as one week or more of a constantly elevated, expansive, or irritable mood and constantly increased goal-directed activity or a pronounced increase in energy. In addition, a patient presents with three or more of the following symptoms: Inflated self-esteem or grandiosity, Reduced need for sleep, Increased talkativeness, Distractibility, Flight of ideas or racing of thoughts, Increased goal-directed activity, and Increased involvement in high-risk activities (McIntyre et al., 2020).

The patient exhibits symptoms of a manic episode, including an elated mood, sleeping for a few hours, excessive talking, distraction, engaging in excessive activities, and pressure of speech. Besides, the patient reports that the manic episodes alternate with depressed episodes, which is characteristic of Bipolar disorder.

Schizophrenia: Schizophrenia presents with features of psychosis, whereby an individual losses contact with reality. The diagnostic criteria include the presence of hallucinations, delusions, disorganized speech and behavior, cognitive deficits, flattened affect, and impairment in occupational and social functioning (McCutcheon et al., 2020). Schizophrenia is a differential diagnosis owing to the patient’s positive psychotic features like delusions, disorganized speech, and occupational dysfunction. However, the client also experiences depressive episodes, which rule out schizophrenia as a primary diagnosis.

Major Depression:

Major depression is a mood disorder characterized by sadness/low mood, severe or reduced interest or pleasure in activities that is persistent enough to impair functioning. The diagnostic criteria include: Depressed mood most of the day; Significantly reduced interest or pleasure in almost all activities; Significant weight changes or appetite changes; Sleeping disturbances; Psychomotor agitation or retardation; Fatigue or low energy levels; Feelings of worthlessness/excessive guilt; Reduced ability to think or concentrate; Recurrent thoughts of death or suicide (Christensen et al., 2020).

Major depression is a differential based on the patient’s history of having episodes characterized by a low mood, diminished interest in painting, increased appetite, weight gain, and hypersomnia. Nonetheless, the patient’s depressive episodes alternate with manic episodes, making major depression an unlikely diagnosis.

Case Formulation and Treatment Plan:

Pharmacologic plan: Lithium 300 mg oral dose twice a day. Lithium is a first-line medication for long-term prophylaxis in bipolar disorder and treats acute mania (Shah et al., 2018).

Psychotherapy plan: Weekly Interpersonal therapy to help the client better cope with challenges of daily living and adjust to a new way of identifying himself.

Health education: The client will be advised to avoid stimulant drugs and alcohol and to reduce sleep deprivation. He will also be educated on recognizing early signs of relapse (Shah et al., 2018). He will be recommended to have finger-like foods during manic episodes to ensure he meets his daily caloric intake.

Referral: Referral to a consultant psychiatrist if manic symptoms do not improve.

Follow-up: The client will be scheduled for a follow-up after four weeks to evaluate progress and medication side effects (Shah et al., 2018).

Reflections: If I were to conduct the session, I would use mania screening tools like the Young Mania Rating Scale to assess the severity of the client’s manic symptoms. I would also educate the patient about activities he can engage in during manic episodes to help channel his energy to constructive activities in addition to painting. In addition, I would include the patient’s family in the patient’s management since they are crucial in helping the patient at home and preventing relapse.

References

Christensen, M. C., Wong, C. M. J., & Baune, B. T. (2020). Symptoms of major depressive disorder and their impact on psychosocial functioning in the different phases of the disease: do the perspectives of patients and healthcare providers differ? Frontiers in Psychiatry, 11, 280. https://doi.org/10.3389/fpsyt.2020.00280

McCutcheon, R. A., Reis Marques, T., & Howes, O. D. (2020). Schizophrenia-An Overview. JAMA psychiatry, 77(2), 201–210. https://doi.org/10.1001/jamapsychiatry.2019.3360

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. Lancet (London, England), 396(10265), 1841–1856. https://doi.org/10.1016/S0140-6736(20)31544-0

O’Donovan, C., & Alda, M. (2020). Depression preceding diagnosis of bipolar disorder. Frontiers in psychiatry, pp. 11, 500. https://doi.org/10.3389/fpsyt.2020.00500

Shah, N., Grover, S., & Rao, G. P. (2018). Clinical Practice Guidelines for Management of Bipolar Disorder. Indian journal of psychiatry, 59(Suppl 1), S51–S66. https://doi.org/10.4103/0019-5545.196974