Focused SOAP Note and Patient Case Presentation
Assignment 2: Major depressive disorder
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 & Episodic/Focused SOAP Note Exemplar 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.
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 study for your clinical patient. In your presentation:
- Dress professionally with a lab coat 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., do not use the patient’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 normal(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 patient’s symptoms.
Plan: What was your plan for psychotherapy? What was 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 be sure to include at least one health promotion activity and one patient education strategy.
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.
By Day 7 of Week 3
Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of each page that is initialed and signed by your Preceptor.
Submission and Grading Information
Solution
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): Patient N.M presents to the clinic with his wife with complaints of low moods, lost interest in the pleasurable activities that he once enjoyed, no longer enjoys spending time with family or friends, and has been contemplating suicide.
HPI: The client a 42-year-old Caucasian male presents to the clinic with his wife. He complains of having experienced low and sad moods, having lost interest in activities that he once considered pleasurable and having suicidal thoughts. The patient lost his job as a supervisor following the COVID-19 disruptions and has been home without any source of income. He has almost depleted his savings and is concerned about the welfare of his family. He however hopes to secure employment and continue supporting his family
Substance Current Use: Patient N.M admits to taking five beers every night
Medical History:
- Current Medications: No current medications
- Allergies: No reported allergies
- Reproductive Hx: The patient has no history of sexually transmitted illnesses
ROS:
- GENERAL: Increase in weight
- HEENT: No vision changes, no vertigo, and no eye pain. No heart burn, no sour taste
- SKIN: Warm to touch
- CARDIOVASCULAR: Denies chest pain. No palpitations, no edema
- RESPIRATORY: Denies cough, shortness of breath, wheezing
- GASTROINTESTINAL: No constipation, diarrhea or vomiting, or loss of appetite
- GENITOURINARY: No changes in urinary pattern, no incontinence
- NEUROLOGICAL: Denies confusion, dizziness, tingling or weakness
- MUSCULOSKELETAL: No weaknesss of pain on the joints
- HEMATOLOGIC: Has no history of anemia
- LYMPHATICS: Has no swollen or enlarged lyph nodes. No history of splenectomy
- ENDOCRINOLOGIC: No thyroid complications
Objective:
Diagnostic results: Screening with the Beck Depression Inventory indicates that the patient suffers from severe depression. The patient scored 31. The instrument’s scoring indicates that individuals scoring between 30 and 63 have severe depression (Maurer et al., 2018).
Assessment:
Mental Status Examination: He is a 42-year-old caucasan male who looks like his age. He cooprates with the therapist. He is oriented to time and place. He is well groomed. He shows normal moto acivity. He has a clear and logical speech. There is no evidence of illogical thought process or speech. He has an pprorpiate affect and his facial expressions align with the situation. He has no signs of hallucinations. He acknowledges to having suicidal ideas. He has agood memory and concentration.
Diagnostic Impression: The diagnostic impression is major depressive disorder. The differential diagnosis are Bipolar disorder and adjustment disorder.
A major depressive disorder is a primary diagnosis for the patient based on the scoring on the BDI screening tool. According to the DSM-5 diagnostic criteria, a patient must present with 5 or more symptoms for two weeks. The symptoms include depressed mood, loss of pleasure, weight gain or loss, insomnia, and psychomotor agitation or retardation (American Psychiatric Association, 2013; Mullen, 2018).
Bipolar disorder is a psychiatric condition, which is associated with an episode of mood swings ranging from manic highs to depressive lows. Manic episodes are characterized by symptoms like high energy, a decreased need for sleep, and loss of touch with reality. The depressive lows are characterized by a loss of interest in daily activities, low energy, low motivation and could sometimes be associated with suicidal thoughts (McCormick et al., 2015).
Adjustment disorder with depressed mood is a stress-related condition, which is associated with a stressful or unexpected event. Stress is likely to cause problems at work, school, or home. The DSM-5 diagnostic criteria is the presence of emotional or behavioral symptoms within three months, experiencing more stress than normal in response to stressful events, and symptoms not being at of any other mental health disorder.
Reflections:
What I would do differently with this patient would be the use of family therapy rather than individual therapy. I believe that family therapy would result in the creation of a conducive support and coping environment for the patient and subsequently work on his social interactions with other family members and friends.
Case Formulation and Treatment Plan:
The treatment plan for the patient was a combination of both therapy and pharmacological agents. The most effective therapy that would result in remission of symptoms would be cognitive behavioral therapy, which focuses on the restructuring of thoughts resulting in behavior modification (Culpepper et al., 2015; Wheeler, n.d). Besides therapy, the patient would highly benefit from antidepressant medications such as the SSRIs like citalopram, fluoxetine, and paroxetine. I put him under citalopram 20 mg daily and cognitive therapy which were effective in managing of his symptoms.
The patient was adviced to continue with the mediation until instructed by a physician. Discontinuation of the medication abruptly may result in side effects while at the same time time resulting in a relapse. Citalopram takes 4 to 6 weeks to work. Some of the side effects that a patient should expeirnce include but not limited to tiredness, dry mouth and sweating which might go awy within a couple of weeks.
Pateints taking Citalopram should not yake St John’s wort as it is likely to increase the risk of side effects. The patient my be put off the drug gardaully to lower the prevalence and severity of the side effects. The patient should call the doctor is he develops thoughts about harming himself, has constant headaches, vomiting bloodo r dark vomit, bleeding from the gums and long lasting confusion.
The pateint should call 911 if he is wheezing, has chest tightness, has trouble breathing, has swelelings on the mouth, lips, throat or if the skin becomes itchy, red and swollen.
I reviewed hospital records for collaborative information
Time was allowed for the patient to ask questions. He seemed to follow and understand the discussion. He agreed to follow the regimen as instructed. Follow up with PCP as needed and/or for:
Return to clinic:
The patient was required to go back to the clinic for follow up after four weeks of taking medicine and attending therapy.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Culpepper, L., Muskin, P. R., & Stahl, S. M. (2015). Major depressive disorder: understanding the significance of residual symptoms and balancing efficacy with tolerability. The American journal of medicine, 128(9), S1-S15.
Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: screening and diagnosis. American family physician, 98(8), 508-515.
McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 27(9), 530–542. https://doi.org/10.1002/2327-6924.12275
Mullen S. (2018). Major depressive disorder in children and adolescents. The mental health clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275
Wheeler, K. (Ed.). Psychotherapy for the advanced practice psychiatric: A how-to guide for evidence-based practice (2nd ed.). New York: Springer Publishing Company