Instructions_Assignment 2_ Focused SOAP Note and Patient Case Presentation
ligiarivera
Week7_Instructions_Assignment2_FocusedSOAPNoteandPatientCasePresentation.docxCASE STUDY:
The patient is a 34-year-old Hispanic female, who reports having a history of mental illness remarkable for some depression and anxiety over the last 2 years, who came to our clinic voluntarily for follow up after she was discharge from the crisis unit at Palmetto Hospital. Patient was Baker Act and admitted in involuntary status with symptoms of depression and passive death wishes. As per medical records the patient reported that over the last several days, she had been feeling somewhat anxious, sad, depressed, and overwhelmed, complained of having multiple stressors that led her feel overwhelmed and in distress and that most recently she was having perception idea that she was doing something bad against her son such as for example, she was cleaning the dishes and she used to see her of grabbing a knife or a sharp object and hurting him. She stated that, that was a very disturbing idea, very ego-dystonic that she did not want to have, but she was not able to stop thinking about that, even she tried to and because of that, she became depressed, overwhelmed, hopeless, and wanted to hurt herself rather than harming him. She also stated that most recently she became somewhat erratic,disorganized, not able to sleep for several days, having some paranoid ideation and becoming religiously preoccupied. During the initial psychiatric evaluation, patient reported that she had two similar episodes for the first time in her life in 2021, for which reason, she was admitted into the hospital and continue outpatient treatment, but she stated that recently her psychotropic medications were modified and the antipsychotic medication that she was taking was discontinued.
PAST PSYCHIATRIC HISTORY:
Evaluated and treated twice during 2021 in the psychiatric facility in Texas, subsequently outpatient followup. Patient and her family moved to Miami in March 2022. Taking medications such as Paxil and an antipsychotic medication that she cannot recall, which was discontinued 2 months ago.
FAMILY HISTORY OF MENTAL ILLNESS:
The patient's maternal aunt suffers from depression.
SUBSTANCE ABUSE HISTORY:
Denied.
PAST MEDICAL HISTORY:
Remarkable for thyroid carcinoma, which was removed.
|
Respiratory Rate |
18 br/min |
|
Cuff Location |
Left arm |
|
Blood Pressure Position |
Sitting |
|
Peripheral Pulse Rate |
75 bpm |
|
Systolic Blood Pressure |
121 mmHg |
|
Diastolic Blood Pressure |
72 mmHg |
|
Mean Arterial Pressure, Cuff |
88 mmHg |
|
Temperature Oral |
36.6 DegC LOW |
MENTAL STATUS EXAMINATION:
The patient appears awake, alert, and oriented x3. Dressed casually. Fair hygiene. Fair eye contact. Psychomotor, neutral. Presenting a spontaneous speech, normal rate and volume, relevant, coherent. Mood is anxious, nervous,fearful, sad, and depressed. She complains of feelings of loneliness and apathy. Denies any command hallucination or suicidal thoughts at this moment.Acknowledging having death wishes in the past but not now, somewhat religiously preoccupied, but denies any other delusions or symptoms of psychosis. Intelligence is average. Insight and judgment are adequate. Recent and remote memory is intact.
DIAGNOSIS:
Axis I: Major depressive disorder with psychotic features. Rule out bipolar
disorder.
Assignment 2: Focused SOAP Note and Patient Case Presentation
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
· 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 “normal” (rather than specific value). Abnormal results should be reported as a specific value.
· 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 patient’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.
· At least 3 references
· Review the Exemplar and use the template to complete the assignment.
