· Premenstrual Dysphoric Disorder SOAP Note
Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.(Premenstrual Dysphoric Disorder SOAP Note Essay)
· 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: As I mentioned above let me know your thoughts about what may be missing.
- 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=1sLinks to an external site.
- Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://waldenu.instructure.com
A copy of the transcript of the video is in the additional box below.
Depression
Premenstrual dysphoric disorder
Seasonal affective disorder (MDD with Seasonal Variation)
agomelatineamitriptylineamoxapinearipiprazole(adjunct)brexpiprazole (adjunct)bupropioncitalopramclomipraminecyamemazinedesipraminedesvenlafaxinedothiepindoxepinduloxetineescitalopramfluoxetinefluvoxamineiloperidoneimipramineisocarboxazidketaminelithium (adjunct)l-methylfolate (adjunct)
lofepraminemaprotilinemianserinmilnacipranmirtazapinemoclobemidenefazodonenortriptylineparoxetinephenelzineprotriptyline quetiapine (Premenstrual Dysphoric Disorder SOAP Note Essay)(adjunct)reboxetineselegilinesertindolesertralinesulpiridetianeptinetranylcyprominetrazodonetrimipraminevenlafaxinevilazodonevortioxetine
citalopramdesvenlafaxineduloxetineescitalopramfluoxetineparoxetinepepexevsarafe,sertralinevenlafaxine
Bupropion HCL extended-release
Bipolar depression
Bipolar disorder (mixed Mania/Depression
Mania
lithium (used with lurasidone)lurasidoneolanzapine-fluoxetine combination (symbyax)quetiapinevalproate (divalproex) (used with lurasidone)
aripiprazoleasenapinecarbamazepine
olanzapineziprasidone(Premenstrual Dysphoric Disorder SOAP Note Essay)
aripiprazolelamotriginelithiumolanzapine
aripiprazoleasenapinecarbamazepinelithiumolanzapinequetiapinerisperidonevalproate (divalproex)ziprasidone
· 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: (Premenstrual Dysphoric Disorder SOAP Note Essay)
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-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.).
Submit your Focused SOAP Note.
Rubric
NRNP_6665_Week4_Assignment_Rubric
NRNP_6665_Week4_Assignment_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeCreate 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(Premenstrual Dysphoric Disorder SOAP Note Essay)
15 to >13.0 pts
Excellent
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.(Premenstrual Dysphoric Disorder SOAP Note Essay)
13 to >11.0 pts
Good
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.(Premenstrual Dysphoric Disorder SOAP Note Essay)
11 to >10.0 pts
Fair
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.
10 to >0 pts
Poor
The response provides an incomplete or inaccurate description of 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. Or the subjective documentation is missing.(Premenstrual Dysphoric Disorder SOAP Note Essay)
15 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide:• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses(Premenstrual Dysphoric Disorder SOAP Note Essay)
15 to >13.0 pts
Excellent
The response thoroughly and accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.(Premenstrual Dysphoric Disorder SOAP Note Essay)
13 to >11.0 pts
Good
The response accurately documents the patient’s ROS for pertinent systems. Diagnostic tests and their results are accurately documented.
11 to >10.0 pts
Fair
Documentation of the patient’s ROS is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor inaccuracies.(Premenstrual Dysphoric Disorder SOAP Note Essay)
10 to >0 pts
Poor
The response provides incomplete or inaccurate documentation of the patient’s ROS. Systems may have been unnecessarily reviewed. Or the objective documentation is missing.(Premenstrual Dysphoric Disorder SOAP Note Essay)
15 pts
This criterion is linked to a Learning OutcomeIn 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.(Premenstrual Dysphoric Disorder SOAP Note Essay)
20 to >17.0 pts
Excellent
The response thoroughly and accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the disorders selected.(Premenstrual Dysphoric Disorder SOAP Note Essay)
17 to >15.0 pts
Good
The response accurately documents the results of the mental status exam. Response lists at least three distinctly different and detailed possible disorders in order of priority for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the disorders selected.(Premenstrual Dysphoric Disorder SOAP Note Essay)
15 to >13.0 pts
Fair
The response documents the results of the mental status exam with some vagueness or innacuracy. Response lists at least three different possible disorders for a differential diagnosis of the patient and provides a justification for each, but may contain some vagueness or innacuracy.(Premenstrual Dysphoric Disorder SOAP Note Essay)
13 to >0 pts
Poor
The response provides an incomplete or inaccurate description of the results of the mental status exam and explanation of the differential diagnoses. Or the assessment documentation is missing.
20 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy.
25 to >22.0 pts
Excellent
The response provides an evidence-based, detailed, and appropriate plan for psychotherapy for the patient. The response provides an evidence-based, detailed, and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A strong rationale for the plan is provided that demonstrates critical thinking and content understanding. … The response includes at least one evidence-based health promotion activity and one evidence-based patient education strategy.(Premenstrual Dysphoric Disorder SOAP Note Essay)
22 to >19.0 pts
Good
The response provides an evidence-based and appropriate plan for psychotherapy for the patient. The response provides an evidence-based and appropriate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. An adequate rationale for the plan is provided. … The response includes at least one health promotion activity and one patient education strategy.
19 to >17.0 pts
Fair
The response provides a somewhat vague or inaccurate plan for psychotherapy for the patient. The response provides a somewhat vague or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is weak or general. … The response includes one health promotion activity and one patient education strategy, but it may contain some vagueness or innacuracy.(Premenstrual Dysphoric Disorder SOAP Note Essay)
17 to >0 pts
Poor
The response provides an incomplete or inaccurate plan for psychotherapy for the patient. The response provides an incomplete or inaccurate plan for treatment and management, including pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. The rationale for the plan is inaccurate or missing. … The health promotion and patient education strategies are incomplete or missing.(Premenstrual Dysphoric Disorder SOAP Note Essay)
25 pts
This criterion is linked to a Learning Outcome• 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.).(Premenstrual Dysphoric Disorder SOAP Note Essay)
5 to >4.0 pts
Excellent
Reflections are thorough, thoughtful, and demonstrate critical thinking.
4 to >3.5 pts
Good
Reflections demonstrate critical thinking.
3.5 to >3.0 pts
Fair
Reflections are somewhat general or do not demonstrate critical thinking.
3 to >0 pts
Poor
Reflections are incomplete, inaccurate, or missing.
5 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate(Premenstrual Dysphoric Disorder SOAP Note Essay) to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
10 to >8.0 pts
Excellent
The response provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.(Premenstrual Dysphoric Disorder SOAP Note Essay)
8 to >7.0 pts
Good
The response provides at least three current, evidence-based resources from the literature that appropriately support the assessment and diagnosis of the patient in the assigned case study.
7 to >6.0 pts
Fair
Three evidence-based resources are provided to support the assessment and diagnosis of the patient in the assigned case study, but they may only provide vague or weak justification.(Premenstrual Dysphoric Disorder SOAP Note Essay)
6 to >0 pts
Poor
Two or fewer resources are provided to support the assessment and diagnosis decisions. The resources may not be current or evidence based.
10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.(Premenstrual Dysphoric Disorder SOAP Note Essay)
5 to >4.0 pts
Excellent
Uses correct APA format with no errors
4 to >3.5 pts
Good
Contains a few (one or two) APA format errors
3.5 to >3.0 pts
Fair
Contains several (three or four) APA format errors
3 to >0 pts
Poor
Contains many (five or more) APA format errors
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation(Premenstrual Dysphoric Disorder SOAP Note Essay)
5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors
4 to >3.5 pts
Good
Contains a few (one or two) grammar, spelling, and punctuation errors
3.5 to >3.0 pts
Fair
Contains several (three or four) grammar, spelling, and punctuation errors
3 to >0 pts
Poor
Contains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
5 pts
Total Points: 100
Premenstrual Dysphoric Disorder SOAP Note Essay
Week 4: SOAP Note
Subjective:
CC (chief complaint): “Yes. So I have a history of taking medications and then stopping them. I don’t think I need them. I feel like the medication squashes who I am.”(Premenstrual Dysphoric Disorder SOAP Note Essay)
HPI: Ms PP is a 28-year-old American female presenting for mental health assessment.
Medication non-adherence Reports not sleeping for 4 or 5 days and hearing things. Reports time of episodes of increased energy characterized by increased activity, difficulty falling asleep, sleeps about 3 and 4 hours, talkativeness, which takes about five days, followed by a period of depressed mood. During episodes of high energy, people say she appears scattered, yet she gets the time to accomplish many things and explore her mind and body. Reports having multiple sexual partners. She says, “It’s exciting and thrilling to find new people to explore sex with. It helps me keep my moods high, high, high”. During the depressive episodes, she experiences low energy characterized by no motivation to do anything, no interest in her creativity, difficulty getting out of bed, and worthlessness. Denies being worried or having anxiety or panic symptoms. Denies repetitive actions. Reports a history of visual and auditory hallucinations. Reports low appetite during creative episodes and sleeps about 12 to 16 hours.(Premenstrual Dysphoric Disorder SOAP Note Essay)
Past Psychiatric History:
General Statement: The client entered treatment for difficulty falling asleep.
Hospitalizations: The client has been hospitalized four times. Last hospitalized in the past spring. Denies detox or residential herbs.
Medication trials: The client reports trying Zoloft, Risperidone, Seroquel, and Klonopin. She had a bad experience with Zoloft as she could get high, could not sleep, and had a racing heart. The client also had a bad experience with risperidone and Seroquel as she gained weight. Klonopin slowed her down.(Premenstrual Dysphoric Disorder SOAP Note Essay)
Psychotherapy or Previous Psychiatric Diagnosis: She has a history of anxiety, depression, and bipolar. Diagnoses not confirmed. Further information from the parents or close friends is needed to ascertain the diagnosis.
Substance Use History: Reports smoking a pack of nicotine and is not ready to stop. Reports taking alcohol and last used at age 19. She tried marijuana and developed paranoia. Denies using methamphetamines, huffing, cocaine, inhalants, sedatives, stimulants, or hallucinogens. Denies the abuse of pain pills, opiates, synthetic, prescribed, or non-prescribed medications. Denies hallucinations, seizures, or blackouts from drugs or alcohol
Family Psychiatric/Substance Use History: The mother had bipolar. The father had a history of substance abuse. The father is in prison for drug abuse. The client thinks the brother is Schizophrenic.
Social History: She was raised by her mother and elder brother. The client has not heard from the father in 8 years. The father was stern with her as a child. She is not married and has no children. She presently lives with her boyfriend but seldom lives with her mother. She works part-time at a bookstore that belongs to her aunt. She is presently in Vo-tech school pursuing cosmetology and writing her biography to be published. Denies legal issues or DUIs. Denies arrest or conviction. She reports being picked up by the police and transported to the hospital following reports of dancing in the field with her guitar and in a nightgown.(Premenstrual Dysphoric Disorder SOAP Note Essay)
Medical History: Has hypothyroidism managed with medication.
Current Medications: Birth control pills for polycystic ovaries.
Allergies: NKFDA.
Reproductive Hx: Regular menses, once a month. She is sexually active and not pregnant.
ROS:
GENERAL: Reports seasonal fatigue and weight loss with certain medications. No fever or chills.
HEENT: No visual or hearing loss. No nasal congestion or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No difficulty with breath.(Premenstrual Dysphoric Disorder SOAP Note Essay)
GASTROINTESTINAL: No nausea, vomiting, or diarrhea. No blood or pain in the abdomen.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: Denies headache or numbness. Normal bowel or bladder control.
MUSCULOSKELETAL: No muscle stiffness, joint, or back pain.(Premenstrual Dysphoric Disorder SOAP Note Essay)
HEMATOLOGIC: No history of bleeding, anemia, or ease of bruising.
LYMPHATICS: No enlarged nodes.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective:
Physical exam: NA
Vital Signs: T- 98.2 R 18 P 92 BP 138/88
Diagnostic results: Bech–Rafaelsen Mania Scale (MAS) would help evaluate the severity of the manic episode, and the Bipolar Inventory of Symptoms Scale (BISS) effectively assesses and confirm BD-I.
Assessment:
Mental Status Examination: The client is well-dressed and awake, alert, and oriented. Has a history of suicide attempts by overdosing on Benadryl. Denies recent history of suicide ideation. Denies self-cutting behavior. Denies visual or auditory hallucinations. Denies having nightmares. She experienced difficulty with recall. She reports being started on some medication whose details she cannot recall.(Premenstrual Dysphoric Disorder SOAP Note Essay)
Diagnostic Impression:
- 46 (F31.74), Bipolar I Disorder, most recent episode manic and in remission – Bipolar depression with most recent episode manic characterized by persistent and abnormal episodes of elevated with increased energy or activity. Individuals experience symptoms such as grandiosity, flight of ideas, decreased need for sleep, distractibility, increased goal-directed activity, and involvement in harmful activities (American Psychiatric Association [APA], 2019).
- 83( F06.34) Substance-induced mood disorder, manic – Substance-induced mood disorder is characterized by elevated mood, increased energy, sleeplessness, rapid thoughts, pressured speech, and distractibility (APA, 2019).
- 83 (F60.3), Borderline personality disorder – Unstable interpersonal relationships and self-image characterize borderline personality disorder. Individuals tend to avoid imagined or real abandonments, identity crises, recurrent suicidal ideation, fatigue, intense anger, impulsivity and paranoia (APA, 2019).(Premenstrual Dysphoric Disorder SOAP Note Essay)
Reflection
The subjective and objective assessment suggests BD-I most recent manic episode and in remission. The client presents symptoms of manic episodes. Marked symptoms such as increased activity and energy, including excessive sexual activity and creativity, leading to the accomplishment of many tasks and sleeplessness (Walden University, 2021), are characteristic of manic episodes of BD-I (Boland & Verduin, 2021).(Premenstrual Dysphoric Disorder SOAP Note Essay)
Symptoms such as elevated energy and mood, sleeplessness, and distractibility (Walden University, 2021) suggest substance-induced mood disorder and manic (Boland & Verduin, 2021). However, the urine tests are negative for any drug. Therefore, the diagnosis is refuted. The symptoms presented by the client, such as depressed mood, difficulty concentrating, worthlessness, and poor interpersonal relationships (Walden University, 2021), suggest Borderline personality disorder (Boland & Verduin, 2021). However, the diagnosis is refuted since further clinical assessments are necessary, as one visit is insufficient for a definitive diagnosis.
In this case, the legal and ethical considerations include informed consent and confidentiality. A practitioner must explain to the client the importance of psychiatric evaluation and the risks and benefits of available interventions to allow them to make an informed decision regarding their health (Boland & Verduin, 2021). In this case, the practitioner should consider the client’s capacity, assure the client of the confidentiality of the psychiatric evaluation process, and use culturally and linguistically appropriate matters to establish a therapeutic alliance. The client’s history of a difficult parent, polycystic ovaries, family with bipolar disorder, and nicotine abuse are predisposing factors to the primary diagnosis.(Premenstrual Dysphoric Disorder SOAP Note Essay)
Case Formulation and Treatment Plan
- Pharmacology – Start the client on Lithium 900 mg/day with Lurasidone 20-80mg/day PO divided q12. The combination is effective for the long-term treatment of treating BD-I symptoms (Calabrese et al., 2017). The combination is safe and well-tolerated.
- Physiotherapy – Recommend the client for cognitive behavioral therapy (CBT). CBT effectively manages BD-I symptoms (Chiang et al., 2017). Individuals are taught to identify triggers and develop appropriate strategies to counter them.
- Education – Discuss with the client the side effects of medication and when to call the clinic or emergency services. Provide the client with emergency services contact 911.(Premenstrual Dysphoric Disorder SOAP Note Essay)
RTC: 4 weeks.
References
American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7th ed.). American Psychiatric Publishing, Inc.
Boland, R., & Verduin, M. (2021). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins.
Calabrese, J. R., Pikalov, A., Streicher, C., Cucchiaro, J., Mao, Y., & Loebel, A. (2017). Lurasidone in combination with lithium or valproate for the maintenance treatment of bipolar I disorder. European Neuropsychopharmacology, 27(9), 865-876. https://doi.org/10.1016/j.euroneuro.2017.06.013
Chiang, K. J., Tsai, J. C., Liu, D., Lin, C. H., Chiu, H. L., & Chou, K. R. (2017). Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PloS one, 12(5), e0176849. https://doi.org/10.1371%2Fjournal.pone.0176849
Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://waldenu.instructure.com
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