· 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)
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 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: What would you do differently with this client if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. 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 that takes into consideration patient factors (such as age, ethn
Case Study: Petunia Park
© 2020 Walden University 1
Case Study: Petunia Park
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.
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
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
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 hig
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
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CC (chief complaint): patient presents to the facility complaining that the drugs she has been prescribed make her feel squashed.
HPI: P. P. is 26years old female who presents to the facility for mental health evaluation. The patient has suffered mental health since teenage. She has been prescribed several medications which she states to stop taking at some point.
Substance Current Use: the patient smokes a pack of cigar daily. No other substance used by patient.
Medical History: patient has been hospitalized about four times. She has not had any surgeries or blood transfusion in the past. Patient states to have been diagnosed with depression, anxiety and even bipolar disorder. The patient is being treated for hypothyroidism as well.
· Current Medications: patient is currently not taking psychotropic medications. She has stopped taking the previously prescribed drug whose name she doesn’t know.
· Allergies: patient has no known allergies.
· Reproductive Hx: patient has a boyfriend, but has also sexual partners. She says that it makes her feel good having multiple sexual partners. Patient is not sure of the last menstrual date, but she states that she is not pregnant. She is taking oral contraceptive as well.
· GENERAL: patient looks healthy. he does not report fatigue or weakness.
· HEENT: head: head is normocephalic, eyes: no blurred vision discharge, or pain. ears: no ringing in the ears, discharge or pain. hearing ability has not diminished. nose: no runny nose or postnasal drainage. throat: no sore throat, no pain or difficulty with swallowing.
· SKIN: no bruising, rashes or tumors
· CARDIOVASCULAR: no palpitations, chest pain or edema reported
· RESPIRATORY: she denies breathlessness, coughing and wheezing.
· GASTROINTESTINAL: patient states that his stomach muscles become tight and feels nauseated.
· GENITOURINARY: no urgency or frequency of urination
· NEUROLOGICAL: she denies seizures, headaches, blackout spells, and numbness
· MUSCULOSKELETAL: she denies stiffness of the joints, pain, tenderness or inflammation
· HEMATOLOGIC: she denies abnormal bleeding or anemia.
· LYMPHATICS: lymph nodes normal size, not enlarged or painful.
· ENDOCRINOLOGIC: no night sweats or increases thirst
Diagnostic results: none
Mental Status Examination:
She a 26-year old female whose stated age seems to correspond with her ages. She is oriented to time, place and person. She is very cooperative and answers questions appropriately. She is clean, and her hair is well combed although her dressing is somehow rough. The patient is hyperactive, playing around with her fingers and laughing more frequently. Her voice is normal, with normal tone and clea
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