NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

NRNP/PRAC 6665 & 6675 Focused SOAP Psychiatric Evaluation Exemplar

 

Subjective

CC: “I worry all the time…about just everything. I don’t know”.

HPI: Dev is a 7-year-old male who presented accompanied by his mother with complaints about worrying all the time about everything. Dev reports that he normally has a lot of bad dreams as he is always dreaming that he is lost and cannot find his mother and brother. He states that he does not like dark and therefore the mother puts him in the light night and leaves the door open as he sleeps so that he is assured the mother is really there. He also reports that he worries a lot while at school about his mother and brother. Dev states that nobody likes him at school and his peers call him Mr. Smelly. He admits that being called names makes him feel really bad. Dev fears that his mother might also not come home any longer like his dad stopped going home. The mother reported that his father died during a military mission. The worry has affected Dev’s functionality because he does not focus while at school and normally get in trouble for always looking out the window. The mother reports that Dev is always very anxious and worried. He throws things around the house and gets in trouble at school for throwing things. He has sleep difficulties and gets up often. The mother reports that Dev is always complaining of stomach aches and headaches. Dev wets the bed at night. He does not eat and has long 3 pounds in the last three weeks. The mother adds that physical illness was ruled out by the pediatrician.

Past Psychiatric History: Dev does not have a history of mental illness

Hospitalizations: N/A

Medication Trials: N/A

Substance Current Use and History: N/A

Family Psychiatric/Substance Use History: No known history of mental illness in the family.

Psychosocial History: Dev lives with his mother and little brother. His father died during a military mission. However, Dev believes the father left and never returned. He attends school but does not like school because his classmates call him names. Dev reports that he does not like playing with the little brother because he “smells”. Dev always wants to be at home. He does not like being at school.

Medical History: N/A.

Current medications: None

Allergies: N/A

 

Physical Review of Symptoms: 

General: Mother reports weight changes.

HEENT: Reports headache.

Cardiovascular:  N/A

Respiratory:  N/A

Abdominal: Reports stomach ache

GU: Wets bed at night

Neuro: N/A

Musculoskeletal: N/A

Hematology: N/A

Psychiatric Review of Symptoms: 

Anxiety: Anxious and worried

Psychotic symptoms: Reports feeling worried and anxious. Reports sleep difficulties.

Eating symptoms: Reports weight loss and loss of appetite

Objective

Physical Exam:

Weight: 25 kgs; BP 118/75; Heart rate 76; RR 19; Temp 35.5 ⁰ C

Diagnostics

• DSM-5 diagnostic criteria: The DSM-5 diagnostic criteria will be utilized to diagnose the psychiatric disorder for Dev. Dev reported anxiety, excessive worrying, poor concentration, sleep difficulties, irritability, loss of appetite and weight changes.

 

Assessment

Mental Status Examination:

Dev is a 7-year-old male who appears underweight but adequately developed for his age. He is well oriented to time, event and place. He maintains eye contact during the interview but loses focus and keeps chuckling sometimes. No notable tics or gestures. Concentration and attention are somewhat poor. Cognitive function is intact and age-appropriate. No delusional or paranoid thought process. No visual or audio hallucinations. His memory is intact. No homicidal or suicidal plan.

Differential Diagnosis

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Separation anxiety disorder: Separation anxiety is characterized by symptoms such as refusing to sleep alone, excessive worry about the safety of family members, repeated dreams on separation from loved ones, excessive worry when away from home or family, refusal to go to school, reluctance on being alone, frequent headaches and stomachaches, being overly clingy, tension, excessive worry about the safety of self, excessive worry while sleeping and tantrums when separating from parents or caregivers (Phillips et al., 2020). Dev manifests the majority of these symptoms. The symptoms have impacted her functionality as he is not functioning well at school. Therefore, the most probable diagnosis for Dev is separation anxiety disorder.

Generalized anxiety disorder (GAD): GAD is characterized by uncontrollable and excessive worry about numerous events. GAD is normally accompanied by physical symptoms like headaches, stomachaches, muscular tension, and heart palpitations. Children with GAD normally worry excessively regarding their safety, family safety, academic performance, or natural disasters (Walsh et al., 2021). However, the client in this case study did not present with symptoms like muscle tension and heart palpitations and his anxiety was mostly about being separated from his loved one. Therefore, the diagnosis of GAD is ruled out.

Adjustment disorder: This is a behavioral or emotional response to an event that is stressful for example loss of a loved one. Dev lost his father and therefore his symptoms may be a response to the father’s disappearance. However, adjustment disorder is characterized by symptoms such as sadness, hopelessness, sleep difficulties, appetite changes, weight changes, and other symptoms that characterize depression (O’Donnell et al., 2019). However, even though Dev reported appetite and weight changes, sleep difficulties, and concentration problems, he manifested anxiety symptoms and thus the diagnosis of adjustment disorder is ruled out.

Functionality: The symptoms have impacted the client’s functionality as he is not able to focus at school and reported that he does not want to be at school as he always wants to be close to his mother and brother to avoid worrying about their safety.

Reflections

The death of Dev’s father is the main trigger to the symptoms of separation anxiety disorder. Dev is not aware that the father died and thinks that the father left and never to come back. As a result, he is excessively worried about his mother leaving too. The treatment needs to focus on teaching Dev how to control his anxiety by helping him adopt a more positive thinking pattern.

Plan

• Cognitive-behavioral therapy (CBT): CBT will be appropriate for Dev in order to help him adopt a more positive thinking pattern. This will improve his mood, feelings, and behavior (James et al., 2018). Through CBT, the client will also be taught and equipped with skills on how to cope with anxiety, excessive worrying, and other life difficult situations like being separated from a loved one.
• Educate the client on breathing exercises to relax and maintain calm
• The mother will be educated to ensure that the client adheres to the treatment plan. The mother will also be educated on the importance of providing Dev with the appropriate emotional support and assurance.
• Follow-up after four weeks

References

James, A. C., Reardon, T., Soler, A., James, G., & Creswell, C. (2018). Cognitive-behavioral therapy for anxiety disorders in children and adolescents. The Cochrane Database of Systematic Reviews, 2018(10), CD013162. https://doi.org/10.1002/14651858.CD013162

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

Phillips, K. E., Norris, L. A., & Kendall, P. C. (2020). Separation Anxiety Symptom Profiles and Parental Accommodation Across Pediatric Anxiety Disorders. Child psychiatry and human development, 51(3), 377–389. https://doi.org/10.1007/s10578-019-00949-7

Walsh, K., Furey, W. J., & Malhi, N. (2021). Narrative review: COVID-19 and pediatric anxiety. Journal of psychiatric research, 144, 421–426. https://doi.org/10.1016/j.jpsychires.2021.10.013

 

TOPIC: ANXIETY DISORDER

• Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related 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: Dev Cordoba. You will use this case as the basis of this Assignment.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.

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 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’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 priority 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 patient if you could conduct the session again? Discuss what your next intervention would be if you could 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, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
• Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

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

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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 demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)

EXEMPLAR BEGINS HERE

Subjective:

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.

Or

P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).

Assessment:

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. 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 literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).

Case Formulation and Treatment Plan

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.  *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?

Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).

Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.

Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):

Client was encouraged to continue with case management and/or therapy services (if not provided by you)

Client has emergency numbers:  Emergency Services 911, the  Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)

Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)

Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)

Follow up with PCP as needed and/or for:

Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)

Return to clinic:

Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.

 

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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