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 non pharmacologic 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.).
all i need is paraphrazing this work sample.
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Week 4 Assignment: Assessing, Diagnosing, and Treating Adults with Mood Disorders
Joshua Honore
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Dr. Wendy Hopkins
June 26, 2022
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Assessing, Diagnosing, and Treating Adults with Mood Disorders
Mood disorders include some psychiatric diseases that may affect an individual’s mental
health and state of well-being (Kalin, 2020). These illnesses affect how an individual conducts
daily activities and how they interact with others. However, it is important to note these illnesses
can be treated and managed successfully using psychotropic medications and psychotherapy.
This paper involves the development of a SOAP note with the basis of evaluating a client in the
case study provided in the week’s assignment. The paper will also include a comprehensive
assessment for the client, possible diagnosis for the client’s condition, and a treatment plan
including the best and current evidence-based practice and clinical guidelines on nurse practice.
Focused SOAP Note
Subjective:
CC: “In the past, I have used prescribed medications for a short while and then stopped using
them. The reason for that is I don’t need them. The medication squashes my creativity and the
essence of who I am.”
HPI: Petunia Park (P.P) is a 26-year-old Caucasian female who came into the clinic for an
assessment on her mental health. P.P reported that she has been previously admitted to the
hospital four times for issues about her mental health. According to the client, she was first
admitted into the hospital as a teenager by her mother after she went for almost 5 days without
getting any sleep. Secondly, in the year 2017, she was also admitted into the hospital for an
attempted suicide due to a Benadryl overdose. She also admitted that in the same period, she
would hear voices. The client also reports to being hospitalized after being found by police men
dancing around in a field while wearing a nightgown and playing her guitar. However, since the
client has no memory of the incident, she feels that her mother might have made up this story as
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an effort force her to go back to live with her boyfriend. The client admitted to previous
diagnosis’ of having mental health issues i.e. depression, bipolar disorder and anxiety. She was
also prescribed Zoloft in the past and reported that the medication made her feel really “high”
and caused her lack of sleep because her thoughts would race. The client was also prescribed
with Risperdal and Seroquel that she stopped taking because they caused her to put on more
weight. Taking Klonopin slowed the patient down according to the patient she didn’t like that
either. The client reported that at times, she didn’t have any energy to get out of bed, she lacked
motivation to do some of the things she loved. This happened four or five times yearly. She
would have no interest in things she enjoys, and she would feel worthless. P.P also reported
moments of “creativity” where she had busts of a lot of energy and during those times, she would
get lots of things done. She reported that these times when she had high energy, she would go
four or five days without sleeping. The client reported that some of her friends would tell her that
she would talk a lot during these times. P.P reported moments when her mind would be scattered
and she reports that she would engage in sex with multiple people during these times. This is
because as she reports, it is exciting and thrilling to explore new sexual experiences with other
people and these experiences would help to keep her mood high. The client reports that those
periods would occur for almost 7 days at a time. On an average day, the client sleeps between 5-6
hours every night but on days when she was “creative”, she would go without sleep or sleep for 3
hours in a week. Additionally, the client reports that after her high energy episodes, she “crashes”
and sleeps for 12-16 hours a day. The denies having any suicidal tendencies or thoughts of
harming others. She denies visual, auditory hallucinations or blackouts, but she admits to hearing
voices in the past that tell that she is wonderful just as she is. The client reported that during her
“creative” episodes, she misses most meals because she is too busy to eat, but when she crashes
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and gets to her “resting” state, she would eat everything. P.P basically lives with her boyfriend
but at times she would stay with her mother during times that her boyfriend would get mad at her
due to her habit of sleeping with other men during episodes of her “creativity”. The client grew
up with her mother and older brother being her parents. The client has not and isn’t currently
married and she has no children. The client also works part-time at bookstore owned by her Aunt
but regularly misses work when she feels depressed which her Aunt understands. She is currently
studying cosmetology at a local vocational school and she wants to be a make-up for the movie
stars. She also reports that for fun, she writes her life story that she states will be published and
she painting like Picasso. The reports that will be selling her paintings to movie stars.
Family History: Mother previously attempted suicide which was not successful. Mother was
diagnosed with Bipolar disorder by a healthcare provider. Father is in prison for years due to
drugs. She reports that her brother has a history of mental health problems but has never been
treated or diagnosis diagnosed for. No other family members with a history of mental health
problems.
Substance Current Use: Client denies any current substance abuse issues. Client reports using
cannabis once but since she became paranoid after using the substance, she stopped using it. She
admitted to smoking cigarettes, one pack per day. Denies any alcohol consumption but admits to
taking one drink at age 19.
Current Medications: On birth control. No other medications.
Allergies: Denies any allergies.
Reproductive History: Client reported regular menstrual cycle with her last period being one
month ago. Never pregnant, no children
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Medical History: Client suffers from hypothyroidism. Previously diagnosed with depression,
anxiety, and bipolar disorder during the times when she was admitted. The client is currently on
birth control to manage polycystic ovarian disease. She has regular cycles and her last periods
were a month ago
ROS:
GENERAL: Admits to having more appetite when “crashing” and reduced or no appetite during
times when she was “creativity”.
HEENT: Denies auditory or visual hallucinations presently but admits to hearing voices in the
past when on long periods of insomnia.
GENITOURINARY: Client has normal and regular menstruation cycles; periods were a month
ago.
NEUROLOGICAL: Client has problems concentrating sometimes and has racing thoughts.
ENDOCRINOLOGIC: Client suffers from hypothyroidism
Objective:
ROS:
GENERAL: The client is clean, dressed modestly and groomed well. She is active and aware of
place and time. She seems to be in a pleasant and accommodating mood.
HEENT: Head is clear of injury or trauma and no deformity observed.
SKIN: Warm and dry, no rashes, cuts or lesions.
CARDIOVASCULAR: Didn’t get evaluated.
RESPIRATORY: No labored breath, wheezing or shortness of breath, coughing or chest pain
NEUROLOGICAL: Alert, oriented, present, pleasant and cooperative.
MUSCULOSKELETAL: No muscle pain or tingling and able to mover all extremities.
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Diagnostic Results:
No tests were carried out for diagnosis. Baseline blood levels needs obtained before prescribing
any medication to avoid adverse effects and bad medicine interactions that could affect the
kidneys, liver, and heart (Liu et al., 2017). Additionally, an EKG (electrocardiogram) would also
be obtained as a precaution and for comparison in the future.
Assessment:
Mental Status Examination (MSE): The client is a 26-year-old Caucasian female that
appears her age. She is clean, dressed appropriately for the purpose and groomed well. The client
is alert and oriented, in a good mood and friendly. Her speech is normal but there are periods of
pressured speech noticed. Thought processes normal at first but illogical at times accompanied
by grand ideas about her life and delusional thinking about becoming famous through doing
make-up, selling her “Picasso” paintings to movie stars, and writing and subsequent publication
her life story. During the assessment process, the provider objectively monitors and evaluate the
moods of the client, her concentrate, thought processes and insight so as to gain a deeper
understanding of the client’s behavior and cognitive abilities.
The client admits to having anxiety sometimes, with periods of “creativity” that lasts
approximately for one week at a time. According to the client, during these periods, she cannot
concentrate, she has a lot of energy, she is very talkative, has an increased sex drive and acts on
her desires with strangers, and gets only three hours of sleep for the whole week. After her
“creativity” period, the client can barely get out of bed, has no energy or motivation to do
anything, loss of interest in doing what she enjoys, and has feelings of worthlessness. Client has
no visual, auditory or visual disturbances currently but she admits to hearing voices in the past
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that told her she was great and talented. Memory, both long-term and short-term are normal. The
client’s judgment and impulse control appears to be compromised during her “creativity”
episodes as she has previously been found by cops in her nightgown at a field with her guitar and
she also admits to enjoying sex with many different people because it elevates her mood even
though she has a boyfriend who lives with her. The client denies any suicidal thoughts or plans
but admitted to an attempted suicide in the past. P.P works part-time a bookstore owned by her
Aunt which she admittedly misses work at times when she feels depressed. Currently, the client
is studying in a local vocational school for a cosmetology degree. Additionally, she enjoys
writing her life story and painting.
Diagnostic Impression:
Bipolar Disorder
Bipolar disorder is a psychiatric disorder that has a major social and psychological
burden to an individual (Mousavi et al., 2021). This is the primary diagnosis for the patient
because her symptoms of manic episodes last for at least one week and they are followed by
episodes of depression. In addition, the client experienced symptoms including an inflated self-
esteem, no sense in the importance of sleep, talks more than needed, has flighty ideas and racing
thoughts, conducts goal-directed activities and is involved in excessive activities that could lead
severe consequences. For example, she engages in sexual activities during here “creative”
episodes which all meet the criteria of a DSM-5 manic episodes (Grunze et al., 2021). In bipolar
I disorder, the patient experiences periods of mania followed by episodes of major depressive
disorder as exhibited by the patient (Mclntyre & Calabrese, 2019).
Generalized Anxiety Disorder
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General anxiety disorder is a psychological condition characterized by extreme anxiety
and worry about normal life events (Patriquin & Matheww, 2017). This diagnosis would be
suitable for the client because she has experienced anxiety which can be easily be mistaken for
racing thoughts and can lead to her impulsive behavior as a way of decreasing feelings of
anxiety, and help elevate her mood. Some of the symptoms experienced by the client that
correspond to this diagnosis include being restless, issues with concentration, being tired easily
and issues sleeping. However, this diagnosis is only secondary because of the manic behavioral
episodes that are best fit for bipolar disorder.
Borderline Personality Disorder
Borderline Personality Disorder is a chronic psychiatric illness characterized by issues in
self-images, impulsivity, suicidal tendencies, and issues with interpersonal relationships
(Kulacaoglu & Kose, 2018). An unstable mood and impulsivity are some of the common
personality traits in borderline personality disorder and bipolar disorders. However, the client
doesn’t meet all of the DSM-5 criteria because her symptoms were different.
Reflections:
The practitioner did a good job when conducting an assessment of the client and
obtaining her past medical history and all the medications she has used. This assessment taught
me the importance of reviewing the past medications of a client since it can be helpful in
determining the best medication to be prescribe for a client. This decision is based on a client’s
past experiences with symptoms and side effects of medications taken in the past. The ethical
and legal considerations for this patient includes a discussion about confidentiality and privacy
that ensure the client is feeling safe enough to discuss her symptoms and past behaviors with the
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healthcare provider. Additionally, the practitioner has to ensure that the client completely
understands what is entailed in her treatment plan so that she could make an informed decision
on her treatment. Apart from that, the client should also be educated on the risks and benefits of
taking psychotropic medications, including their possible side effects and how they would work
to lessening her symptoms. The client’s safety in relation to past behaviors should be evaluated
to ensure that suicidal thoughts or plans are not missed in accordance with ethical guidelines
provided by the principle of non-maleficence. Ethical guideline of autonomy has to be followed
since the client is entailed to the right to make decisions on a treatment plan once they are
informed about all treatment options available to them. For health promotion and disease
prevention, the client can be informed on safe sex practices since she enjoys sex with stranger to
avoid STD’s especially during her manic stages.
Case Formulation and Treatment Plan:
For the client in the case study, the appropriate diagnosis for her condition is Bipolar
Personality Disorder. This was in accordance to her symptoms based on the criteria in the DSM-
5 guidelines. The symptoms included an inflated self-esteem, lack of concern for sleep, wrong
judgment and issues with impulse control as exhibited by promiscuous activity, talkative more
than usual, racing thoughts, illogical thought processes with grand ideas and delusional thinking.
After bouts of “creativity” she client reported that she would lack energy, not getting out of bed,
lack of interest in activities she typically enjoys, lack of motivation and feeling worthless.
The client will be prescribed Lamotrigine 25 mg BID to start and slowly increased in
dosage until the desired results are achieved without side effect. Additionally, the client will be
referred to a psychotherapy program. Since the client about the side effects of some medications
especially gaining weight from past prescribed medications, Lamotrigine was the best choice
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since weight gain has not been recorded as a common side effect. The medication has also been
approved by the FDA for the treatment of Bipolar disorder (Hashimoto et al., 2020). For the
compliance of medication by the client, she will be educated on the time frame that the
medication might take to see an improvement on her symptoms and some of the common side
effects that could be experienced from the medication such as dizziness or nausea (Besag et al.,
2021). Due to such side effect including dizziness, the client can be discouraged about driving
especially after taking the medication. She will also be instructed on the importance of taking
medication as prescribed and is he needs to stop then she should stop gradually rather than
abruptly especially without the knowledge of the healthcare provider. She should also be
educated possible drug interactions of taking this medication with birth control since it can
reduce the effectives of birth control. Therefore, the client can be instructed to use any additional
form of birth control such as condoms when taking the medication.
She can also be educated on the importance of psychotherapy in her treatment plan
because there are studies showing that psychosocial interventions, including CBT, IPSRT, and
family-focused therapy can improve the rate of recovery and reduce a reoccurrence of symptoms
for the client (Smith et al., 2021). The client was also given a number to call in case of any
thoughts of self-harm and told to use the number for emergencies or visit the nearest emergency
room for treatment or evaluation during emergencies. After the treatment, the client is will be
given time any ask questions about her treatment plan or any concerns about the medication she
is prescribed. Additionally, the client will need to attend a follow up session one week after the
session for an assessment of any side effect caused by the medication and the overall progress of
the disease.
Conclusion
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Effective assessment of a patient with mental health issues depends heavily on the ability
of the health provider to get information from the patient. The practitioner in this case study
asked all the necessary used in the patient’s assessment and subsequent treatment. Additionally, I
leant from the case study about the importance of ethical consideration in nurse practice. It is
also important to ensure that patients the required information across stages of the nursing
process. This empowers the patient to make the right decisions about their treatment plan.
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References
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