Assignment 2 PTSD: Focused SOAP Note and Patient Case Presentation
Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 4 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 the Kaltura Media Uploader resource for help creating your self-recorded Kaltura video
Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
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 professionally present yourself.
- 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 the patient 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 is 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. 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 over?
- If you can 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 7
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.
Solution
NRNP 6665: PMHNP Care Across the Lifespan I
Subjective:
CC (chief complaint): flashbacks, involuntary memories, and nightmares
HPI: The patient who is 42 years old for the last 4 weeks has been experiencing intrusion feelings. He is a veteran who served in Afghanistan for 3 years. He has been experiencing flashbacks, involuntary memories, and nightmares, which have resulted in poor sleep and irritability.
Substance Current Use: 3 beers weekly and uses nicotine
Medical History:
- Current Medications: Vitamin D supplements
- Allergies: No known allergies
- Reproductive Hx: No history of STIs
ROS:
- GENERAL: No increase or reduction of weight, no fever or chills or fatigue
- HEENT: No eye pain or redness, no vision changes, no sour taste in the mouth, no sore throat no congestion no sneezing
- SKIN: Skin is warm to touch, no rash, no itching
- CARDIOVASCULAR: denies chest pain, edema, or palpitations,
- RESPIRATORY: No cough or sputum, no shortness of breath, no wheezing
- GASTROINTESTINAL: No constipation, no diarrhea, no abdominal pain no anorexia
- GENITOURINARY: No changes in urine pattern, no color, no incontinence
- NEUROLOGICAL: Denies dizziness, tingling no headache no paralysis no tingling or weakness no confusion
- MUSCULOSKELETAL: no joint pain, no stiffness no weakness of the joints
- HEMATOLOGIC: no bleeding, no bruising, no history of anemia
- LYMPHATICS: has no swollen nodes, has no history of splenectomy
- PSYCHIATRIC: involuntary memories and flashbacks
- ENDOCRINOLOGIC: no history of sweating, heat or cold intolerance, No polyuria or polydipsia
Objective:
Physical exam
Vitals: 95.2, pulse rate 70, Respiration 18, B/P 126/80
Psychiatric: Seems lost in thought, has flashbacks, and involuntary memories
Diagnostic results:
Assessment:
DSM-5 criteria indicate that the patient has intrusion symptoms (involuntary memories, nightmares, and flashbacks) which are one of the four cluster symptoms in PTSD. The other cluster three symptoms include avoidance symptoms, arousal and reactive symptoms, and negative thoughts and feelings (Parekh & Ranna, 2017)
Mental Status Examination:
Mental Status Examination: He is a 42-year old Caucasian male. He cooperates during the session and seems attentive throughout out. He is unkempt with uncombed hair and shabbily dressed. He has normal motor activity during the interview. He does not use correct facial expressions and gestures. He sometimes seems lost in thought. He denies any suicidal thoughts
Diagnostic Impression: Post traumatic stress disorder
Post-traumatic stress disorder (PTSD) is the primary diagnosis. PTSD refers to a psychiatric disorder among individuals that have experienced atraumatic events in their life such as violence, war, personal assault, or rape. According to Ghaffarzadegan (2016) between 11 and 20 percent of US, the military deployed to Iraq and Afghanistan suffer from PTSD. The four cluster symptoms that patients must present with are avoidance symptoms, intrusion symptoms, arousal, and reactive symptoms as well as negative thoughts and feelings.
Differential Diagnoses
Acute stress disorder
Acute stress disorder refers to a condition that develops within a month of experiencing a traumatic event (Meiser-Stedman et al., 2017). The events might include death, a threat to death, and injury to self or others. The traumatic events case fear, helplessness, and horror
Adjustment disorder
Adjustment disorder refers to a mental health illness where individuals experience emotional or behavioral symptoms in response to identifiable stressors (O’Donnell et al., 2017). The stressors must have occurred three months before the beginning of the symptoms. The stressful episodes result in strained relationships at work, school, and home.
Generalized anxiety disorder
Generalized anxiety disorder refers to a disorder whose characteristics include excessive anxiety and worrying which are difficult to control (American Psychiatric Association, 2013). The disorder causes distress, which may last for more than six months. The condition usually occurs during adulthood and takes a chronic cause resulting in reduced quality of life, escalating medical costs as well as impaired functioning.
Major Depressive Disorder
Major depressive disorder refers to a mental health illness where an individual must present with five or more symptoms for at least two weeks. The symptoms include insomnia, loss of pleasure in activities that one enjoyed, a depressed mood, agitation or retardation as well as weight gain or loss (Mullen, 2018).
Reflections:
What I would do differently with the patient is to change the psychotherapy used. Instead of using cognitive behavioral therapy, I would use prolonged exposure therapy. Prolonged exposure therapy is a type of therapy, which is trauma-focused and which has been supported by any nursing literature. The therapy usually lasts for 15 to 90 individual sessions, which could be delivered once or twice a week based on the local arrangement between a patient and the therapist.
Prolonged exposure therapy provides the platform for the individual to alter negative notions while at the same time experiencing experiential learning. Besides experiential learning, during the first sessions, the patient can learn diaphragmatic breathing, which he can use to manage and lower his anxiety levels.
Case Formulation and Treatment Plan:
The treatment plan for the patient was a combination of pharmacological agents and psychotherapy. The patient was put on selective serotine reuptake inhibitors (SSRIs) sertraline. Psychotherapy used was cognitive behavioral therapy, which entails cognitive restructuring allowing individuals to gain control over their fears and distress. Cognitive-behavioral therapy aims at changing the thinking patterns. The strategies involved include individuals learning to recognize distortions, which create problems, having a deeper and better understanding of one’s behavior and other people’s motivation as well as the application of problem-solving skills to cope with situations better in life. The therapy also enables people to have a greater sense of their abilities.
Some of the sides effects of the prescribed medication include nausea, diarrhea, constipation, vomiting, difficulty falling asleep, dry mouth, loss of appetite and heart burn. The patient should alert a physician if the above symptoms do not go away.
The client was encouraged to cpntune with the medication and therapy to minize cases of relapse or adverse events assoicetd with discontinuation of the medication abruptly.
In case of any emergency the client is instructed to call 911 or visit the nearest ER if they become suididal.
The client seemed to understand the discussion and agrees to follow the regimen prescribed and discussed.
The patient is required to retrun to clinical after four weeks for follow up to improve functioning and minimize cases of chornic symptoms or the ned for higher level of care.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
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
Ghaffarzadegan N, Ebrahimvandi A, Jalali MS (2016) A Dynamic Model of Post-Traumatic Stress Disorder for Military Personnel and Veterans. PLoS ONE 11(10): e0161405. https://doi.org/10.1371/journal.pone.0161405
Parekh, M.D., M.P.H., Ranna (2017 January). American Psychiatric Association (APA): What Is Posttraumatic Stress Disorder? Retrieved from: https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment Disorder: Current Developments and Future Directions. International journal of environmental research and public health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537
Meiser‐Stedman, R., McKinnon, A., Dixon, C., Boyle, A., Smith, P., & Dalgleish, T. (2017). Acute stress disorder and the transition to posttraumatic stress disorder in children and adolescents: Prevalence, course, prognosis, diagnostic suitability, and risk markers. Depression and anxiety, 34(4), 348-355.