- 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.
- 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 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 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 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.
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): I’m still having sleep issues’
HPI: C. C. is a 66-year-old caucian male presents for medication management follow up for insomnia. He was initiated on Trazodone last appt which he says was effective for two weeks.
Past psychiatric history– Patient has history of ADHD and anxiety. ADHD was diagnosed t the age of 15 years and Anxiety about 2 years ago. Denies any history of hospitalization due to psychiatry illness.
Medication trials and current medications– Adderral XL 60mg in the morning and Adderral IR 30mg at 1pm for ADHD, Alprazolam 1mg daily for Anxiety and trazodone 50mg at night for insomnia. Newly added medication Temazepam 15mg at bedtime.
Psychotherapy or previous psychiatric diagnosis- No history previous psychotherapy or prior psychiatry hospitalization. During this visit, patient was educated on healthy living lifetyle
Pertinent substance use- Patient denies any substance use. Drinks 2 to 3 bottles of beer socially. Currently smokes 3 to 5 ticks of cigaretes per day
Family psychiatric/substance use. Patient was born in Elgin in 1955. No history of sexual abuse.No known substance abuse in the family. No known family psychiatry history
Social History- Patient lives alone in an apartment. Patient has 2 siblings who lives in another states. Patient’s best friend is G.A. they hange out once every week but has been every other week due to covid. Patient reported he takes about 30 minutes of brisk walk around the neighbourhood as a form of exercise. Patient enjoys spiritual
Allergies- No known allergies
Medical History: No medical history
· Current Medications: Adderral XR 60mg Qam, Adderral IR 30mg at noon for ADHD, Alprazolam 1mg Qday for anxiety, Temazepam 15mg at bedtime. Trazodone 50mg QHS rpn
· Reproductive Hx: Pt is divorced. Patient was previousl marrid for 20 years before getting a divorce. Patient has a girlfriend who he is sexually active with.
ROS:
Vitals: BP 117/82, P- 87,T-97.8, R- 16, Spo2-98% in room air
· GENERAL: No fever, chills, weakness, or fatigue and no weight loss
· · HEENT: Head is Normocephalic and atraumatic, Eye- pupils are equal, no discharges, No double, blurred vision. Ear, Nose, and Throat -No hearing loss, No congestion, no sore throat, and no sneezing
· · SKIN: Skin is warm, No rash or itching
· · CARDIOVASCULAR: No chest pain, No chest pressure, and no edema, No palpitation
· · RESPIRATORY: No respiratory distress.
· · GASTROINTESTINAL: No distension noted, No anorexia and vomiting
· · GENITOURINARY: No burning on urination
· · NEUROLOGICAL: The patient is alert and oriented, no dizziness, numbness, or tingling sensation of the extremities
· · MUSCULOSKELETAL: No muscle pain, No back pain, nobody stiffness, no edema noted
· · HEMATOLOGIC: The patient is not frail and no bleeding
· · LYMPHATICS: No enlarged lymph nodes.
· · ENDOCRINOLOGIC: No reports of polydipsia. Reported sweating and heat intolerance.
Objective:
Diagnostic results: Sleep diary, Actigraphy, Mental history
Assessment:
Mental Status Examination: He is a 66 year-old caucasian male who looks his stated age. He ia alert and orientated to time, place, person and situation. Patient was calm and cooperative with the examiner. He is independent of ADL.He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the
Diagnostic Impression:
Reflections:
Case Formulation and Treatment Plan:
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