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Tag Archives: How are their symptoms impacting their functioning in life?

December 21, 2024
December 21, 2024

Differential Diagnosis Focused Soap Note

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.

 

 

Differential Diagnosis Focused Soap Note

  • 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)

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 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.).

By Day 7 of Week 4

October 15, 2024
October 15, 2024

Patients With Mood Disorders

Assessing and Diagnosing Patients With Mood Disorders

Schizophrenia and Other Psychotic Disorders; Medication-Induced Movement Disorders

 

Patients With Mood Disorders

Accurately diagnosing depressive disorders can be challenging given their periodic and, at times, cyclic nature. Some of these disorders occur in response to stressors and, depending on the cultural history of the client, may affect their decision to seek treatment. Bipolar disorders can also be difficult to properly diagnose. While clients with a bipolar or related disorder will likely have to contend with the disorder indefinitely, many find that the use of medication and evidence-based treatments have favorable outcomes.

  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

Complete and submit your Comprehensive Psychiatric Evaluation, 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? Patients With Mood Disorders,  
  • 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-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.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? 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.).

Training Title 134 Name: Mrs. Patricia Warren

Gender: female Age: 42 years old Background: Patricia was brought in under a emergency evaluation order after her best friend, Felicia, after the police for Patricia locking herself in a closet and screaming loudly for over an hour. EMS was able to calm her with a small dose of Ativan enroute to the emergency department. This is Patricia’s third presentation to the emergency room in 2 weeks. She had one psychiatric hospitalization around this same last year. No self-harm behaviors but has assaulted other in the past. No hx of TBI. Sleeps 1–2-hour increments for total of 6 hrs. daily, refuses to sleep at night. Refused vitals, wt., refuses labs, not cooperative. She obtains SSDI. She lives in Cameron, Montana. She denies ever using any drugs and drinks one glass wine weekly. She has a sister who is five years older, both parents deceased in the last three years. She has no children, her husband is out of town, truck driver. Family history includes that her father had two previous inpatient psychiatric hospitalizations for paranoia Mother had history of bipolar depression. Paternal grandmother had “shock therapy”. Denies history of trauma experience, but her friend reports parents death was extremely difficulty for Patricia. no current legal charges. dropped out of high school in 11th grade, was pregnant and had abortion. allergies: Clozaril

FYI: she is very fidgeting during intake interview; avoid eyes contact Patients With Mood Disorders

00:00:10[sil.] 

00:00:15UNKNOWN Hi, Mrs. Warren, nice to see you again. How are you doing? 

00:00:20Warren You’re with them. 

00:00:20UNKNOWN Pardon me. 

00:00:25Warren I know you are. But you won’t tell me, people like you never do. 

00:00:30UNKNOWN I’m not sure that I follow. 

00:00:30Warren Sure. They dumb just like everybody else. We’re on to you. 

00:00:40UNKNOWN Who do you mean by we? 

00:00:45Warren Mm-hmm. 

00:00:45UNKNOWN You are not going to tell me? 

00:00:50Warren I don’t need to tell you. You have eyes and ears planted everywhere. 

00:00:55UNKNOWN Everywhere meaning other places away from the hospital… 

00:01:00Warren Everywhere, enough set. 

00:01:00UNKNOWN Let me make sure I understand. Are you saying you feel that I or someone else has been spying on you? 

00:01:05Warren I don’t feel that. I know it. You and your people had… I don’t need to explain it, you already know. 

00:01:15UNKNOWN You feel safe here in the emergency department? 

00:01:20Warren There’s nowhere that is safe. Don’t pretend like there is. 

00:01:30END TRANSCRIPT 

Important

Informal blogs, internet posts and websites that are not part of a scholarly review process. This includes popular hospital websites (such as MayoClinic.org), Patient facing websites with information designed for the patient, not the provider (such as WebMD, Healthline and MedicineNet, among many others), and UptoDate.com. Information should not be utilized from UptoDate.com since all information is a synthesis of the most up to date literature available. If you wish to use information from UpToDate, use the original sources, not the UpToDate website. Patients With Mood Disorders

Another student’s work. Regardless of where it is obtained, the use of another student’s written work is never appropriate. This includes use of another student’s work as a “reference”, or exemplar assignment. Templates and examples are often provided in the classroom. If they are not and you would like one, please request this from your instructor.

 

April 19, 2024
April 19, 2024

NRNP 6635 Case study

Training Title 151

Name: Daniela Petrov

Gender: female

Age:47 years old

T- 98.8 P- 84 R 20 B/P 132/90 Ht 5’8 Wt 128lbs

Background: Moved to Everett, Washington from Russia with her parents when she was 16 years old. Currently lives in Boise, Idaho. She has younger 1 brother, 3 older sisters. Denied family mental health or substance use issues. No history of inpatient detox or rehab denied self-harm hx; Menses regular. uses condoms for birth control Has fibromyalgia. She works part time cashier at Save A Lot Grocery Store. Dropped out of high school in 10th grade. Sleeps 5-6 hours on average, appetite good.

NRNP 6635 Case study

NRNP 6635 Case study

Symptom Media. (Producer). (2018). Training title 151 [Video].

https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-151

  • Review this week’s Learning Resources and consider the insights they provide.
  • Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment.
  • By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

NRNP 6635 Case study

BY DAY 7 OF WEEK 8

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate 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-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.

NRNP 6635 Case study

•          Reflection notes: What would you do differently with this client if you could conduct the session over? 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.). APA.

March 14, 2024
March 14, 2024

Mood Disorders Case Assessment

 Name: Ms. Rosario Campbell

Gender: female

Age:25 years old

T-97.7 P-70 R-18 118/72 Ht 5’3 Wt 123lbs

Background: African American.

Mood Disorders Case Assessment

chief complaint: PTSD, Low mood and Suicidal thoughts. The client said she was diagnosed with depression at age 13 or 14 and was prescribed antidepressants, which she stopped taking in order to enlist in the military.  Currently living off-base in El Paso, Texas, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Grew up in McAllen TX with both parents and one brother. Completed education through high school. Currently partnered. No children. Mother history of depression; brother hx of cannabis use. No medical history. No legal hx; allergy: cipro previous medication trials: sertraline, fluoxetine both with good effects when taking. Symptom Media. (Producer). (2017). Training title 18 [Video].

Mood Disorders Case Assessment

TO PREPARE

  • Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing mood disorders.
  • Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
  • By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Identify at least three possible differential diagnoses for the patient.

Mood Disorders Case Assessment

Complete and submit your Comprehensive Psychiatric Evaluation, 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-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.

Reflection notes: What would you do differently with this client if you could conduct the session over? 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.). Use APA referencing style.