In this post, you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

Review Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.

Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.

Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.

Consider what history would be necessary to collect from this patient.

Consider what interview questions you would need to ask this patient.

Consider patient diagnostics missing from the video: 

Provider Review outside of interview:

Temp 98.2 Pulse  90 Respiration 18  B/P  138/88

Laboratory Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H).

MAIN ASSIGNMENT: 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 nonpharmacologic 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.).

Reading Resources

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th 

ed.). Wolters Kluwer.

Chapter 8, “Mood Disorders”

Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. 

Springer.

Chapter 11, “Mood Disorders”

CrashCourse. (2014, September 8). Depressive and bipolar disorders: Crash course psychology #30Links to an external site. [Video]. YouTube. https://youtu.be/ZwMlHkWKDwM https://www.youtube.com/watch?v=ZwMlHkWKDwM&t=1s

Walden University. (2021). Case study: Petunia Park. Walden University 

Blackboard. https://waldenu.instructure.com

NRNP 6665 WEEK 4 ASSGN: ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS

In this post you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

Review Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.

Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.

Review the video, 
Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.

Consider what history would be necessary to collect from this patient.

Consider what interview questions you would need to ask this patient.

Consider patient diagnostics missing from the video: 

Provider Review outside of interview:

Temp 98.2
Pulse  90
 Respiration 18
  B/P  138/88

Laboratory Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H).

MAIN ASSIGNMENT: 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 nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and manag

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the
Focused SOAP Note Evaluation Template

AND
the Rubric
as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide.

In the
Subjective section, provide:

· Chief complaint

· History of present illness (HPI)

· Past psychiatric history

· Medication trials and current medications

· Psychotherapy or previous psychiatric diagnosis

· Pertinent substance use, family psychiatric/substance use, social, and medical history

· Allergies

· ROS

Read rating descriptions to see the grading standards!

In the
Objective section, provide:

· Physical exam documentation of systems pertinent to the chief complaint, HPI, and history

· Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.

Read rating descriptions to see the grading standards!

In the
Assessment section, provide:

· Results of the mental status examination,

presented in paragraph form.

· At least three differentials with supporting evidence. List them from top priority to least priority. Compare the
DSM-5-TR diagnostic criteria for each differential diagnosis and explain what
DSM-5-TR 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

.

·
Read rating descriptions to see the grading standards!

Reflect on this case. Include: 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 taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The FOCUSED SOAP psychiatric evaluation is typically the
follow-up visit patient note. You will practice writing this type of note in this course. You wi

[removed]

[MUSIC PLAYING] DR. MOORE: Hi. Good afternoon. My name is Dr. Moore. Am I understanding you’re here
for a mental health assessment today? PETUNIA PARK: That’s right. DR. MOORE: OK. So to make sure I have the right
patient and the right chart, can you tell me your name
and your date of birth? PETUNIA PARK: Yes. I’m Petunia Park. My birthday is July 1, 1995. DR. MOORE: And can you tell
me what today’s date is? PETUNIA PARK: So
it’s December 1. DR. MOORE: Do you know the year? PETUNIA PARK: 2020. DR. MOORE: And what day
of the week is this? PETUNIA PARK: It’s Tuesday. [CHUCKLING] DR. MOORE: And do you
know where we are today? PETUNIA PARK: Yes I am here
in the beautiful, sunny office at the clinic. DR. MOORE: OK, great. Thank you. So can you tell me a little bit
about why you’re here today? What brings you here today? PETUNIA PARK: Yes. So I have a history of taking
medications and then stopping them. I don’t think I need them. I really feel like the
medication squashes who I am. DR. MOORE: OK, OK. So I’m going to be able
to help you with that. But to begin, I’m going
to ask you some questions about your family. I’m going to ask you some
history-type questions. I’m going to ask
you some symptoms that you might be having. And all of these
questions are going to help me work with you
on a treatment plan, OK? So I would like to
begin with, when was the first time that you
ever had any mental health or substance use
treatment in your life? PETUNIA PARK: OK. Well, when I was a teenager,
my mom put me in the hospital after I went four or five
days without sleeping. I think I may have been
hearing things at that time. [CHUCKLES] I think they
started me on some medication, but I’m not sure. DR. MOORE: Oh, OK so
you were hospitalized. How many times have you been
hospitalized for mental health? PETUNIA PARK: Oh, I’ve been
hospitalized about four times. The last time was
this past spring. No detox or residential
rehabs, though. DR. MOORE: OK, good. Were any of these
hospitalizations due to any suicide gestures? PETUNIA PARK: One was in 2017. I overdosed on
Benadryl, but I’ve not had those thoughts since then. DR. MOORE: Well, I’m very glad
to hear that you’ve not had any of those thoughts since then. And I’m glad that you turned
out OK from that overdose. I’m glad that you’re here today. Can you tell me a
little bit about what you’ve been diagnosed with
during your past treatments? PETUNIA PARK: Well,
I think depression, and anxiety, had some
even say maybe bipolar. DR. MOORE: OK, and
what medications have you been tried on
before for those illnesses? And if you can remember,
what was your reactions to those medications? PETUNIA PARK: Oh, let’s see. Oh, I took Zoloft, and that
made me feel really high. [CHUCKLES] I couldn’t sleep. My mind was racing, and
then I took risperidone. That made me gain
a bunch of weight. Seroquel gave me weight, too. I took Klonopin, and that
seems to slow me down some. I really can’t
remember the othe