It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptom 

Case Study: Petunia Park

© 2020 Walden University 1

Case Study: Petunia Park
Program Transcript

[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?

Case Study: Petunia Park

© 2020 Walden University 2

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

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

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):

HPI:

Substance Current Use:

Medical History:

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Diagnostic results:

Assessment:

Mental Status Examination:

Diagnostic Impression:

Reflections:

Case Formulation and Treatment Plan: 

References

© 2021 Walden University

Page 1 of 3

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 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

.

· 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

!), 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 will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to dem

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Content

Name: NRNP_6665_Week4_Assignment_Rubric

  Excellent Good Fair Poor
Create documentation in the Focused SOAP Note Template about the patient in the case study.

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

Points:

Points Range:
14 (14%) – 15 (15%)

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

Feedback:

Points:

Points Range:
12 (12%) – 13 (13%)

The response accurately describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis.

Feedback:

Points:

Points Range:
11 (11%) – 11 (11%)

The response describes the patient’s subjective complaint, history of present illness, past psychiatric history, medication trials and current medications, psychotherapy or previous psychiatric diagnosis, pertinent histories, allergies, and review of all systems that would inform a differential diagnosis but is somewhat vague or contains minor innacuracies.

Feedback:

Points:

Points Range:
0 (0%) – 10 (10%)

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of pre

Assessing, Diagnosing, and Treating Adults With Mood Disorders

It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.

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

To Prepare

· Review this week’s 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)

The 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 diagno