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Prac 6665 - Focused SOAP Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your classroom courses. Focused SOAP notes, such as the ones required in this course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. 
To Prepare
Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
Create a Focused SOAP Note on this patient using the template provided. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
Please Note:
When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
Then, based on your SOAP note of this patient, develop a video case study presentation. 
Objective: What observations did you make during the psychiatric assessment? 
Assessment: Discuss their 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. Also 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 again? 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.

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 Focused SOAP Note and Patient Case Presentation 

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Subjective:

CC (chief complaint): “I feel weak all the time, nauseated, and I can’t sleep”

HPI: T. L., a 43-year-old African American male presents to the clinic for scheduled review following an earlier diagnosis of major depressive disorder. The patient notes that in the past two weeks he has been experiencing symptoms: trouble sleeping, loss of appetite, nausea, loss of weight, fatigue, and erectile dysfunction. The patient has been taking Prozac to minimize depressive symptoms.

Substance Current Use: No history of substance use

Medical History:

• Current Medications: Prozac 20 mg/daily taken orally for depression

• Allergies: no history of allergy

• Reproductive Hx: heterosexual

ROS:

GENERAL: Weight loss, 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: Nausea. Loss of appetite. No abdominal pain or blood.

GENITOURINARY: No 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:

DSM-5 criteria – major depressive disorder

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Assessment:

Mental Status Examination:

The client is a 43-year-old African American male who appears well-groomed, neat, and appropriately dressed. The patient presents with weight loss, fatigue, lack of appetite, and sleep difficulties. The patient is alert and oriented to the place and time. The patient’s participation level is active and eager to share in the conversation. The client’s speech is clear, coherent with normal volume and tone. His mood appears anxious and intense affect. His mental status awareness is normal. The client denies any thoughts of suicidal and homicidal ideation. He shows no signs of delusional thinking and denies any experiences of hallucinations. Recent memory is good, but the concentration is on and off and the thought process low.

Diagnostic Impression:

The priority diagnosis is a major depressive disorder. This diagnosis is supported by the patient’s history having been diagnosed two weeks ago with the same. Additionally, the DSM-5 criteria analysis shows that the patient exhibits symptoms consistent with depression including depressed mood, significant weight loss, loss of interest/pleasure in doing favorite activities, and feeling of worthlessness (Tolentino & Schmidt, 2018). The second possible diagnosis, in this case, is anxiety, which is supported by the fact that the patient shows an anxious mood. Moreover, the condition is often confused for depression and often occurs as a comorbid. The third possible diagnosis is adjustment disorder with depressed mood. The rationale for this diagnosis is that its symptoms closely resemble those of depression. However, confirmation is based on the presence of a recent trigger/stressor such as grief, which is absent in this case.

Reflections: I believe the case formulation and diagnosis were appropriate in this case given the client’s history and assessment results. However, I learned that it is not important to immediately rule out other possible diagnoses even if the patient had already been diagnosed because the first diagnosis might have missed a comorbid condition such as anxiety existing along with depression. The case gives insight into how patients may respond differently to medications. As some clients will have minimal side effects, others may experience serious side effects, which limit the efficacy and effectiveness of the treatment process (Yokoyama, Okamura, & Takahashi, 2017). Thus, patient education is important on the risks and benefits of medication and what steps to take in case of side effects.

Case Formulation and Treatment Plan: 

Some patients may experience a negative response to medication. The symptoms described by the patient are sometimes experienced by patients when they start to take Prozac. The treatment plan is to combine Prozac with chlordiazepoxide. This combination will be more effective and reduce the side effects experienced by the patient (Ogawa, 2019). The patient will be educated on the drug combination including risks and benefits. For instance, chlordiazepoxide will not be used for more than two weeks as its prolonged use may pose safety issues to the patient including neurotoxicity and dependence (Fulone, Silva, & Lopez, 2017). Once the symptoms have stabilized, the patient can continue taking Prozac. The patient will also be initiated in psychotherapy using CBT to assist him to overcome the negative thoughts that cause a depressed mood. The patient will be given health promotion education on the benefits of staying health through exercise and eating healthy, and avoiding drugs and alcohol and these might impact health outcomes. the health promotion approach will be based of the health promotion model. Additional educational strategy will entail giving the patient a flier with important health information to encourage positive health habits. The patient will be encouraged to adhere to the treatment plan including psychotherapy and drug therapy.

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