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Tag Archives: What is the duration and severity of their symptoms?

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.

December 19, 2023
December 19, 2023

Anxiety Disorder Case Study

Casie Weider Gender: female Age: 53 years old T- 99.0 P- 102 R 24 156/86 Hit 5’4 Wt. 1lbs73 Background: Lith her husband in Memphis, TN, has one daughter aged 25. She has never worked. Raised by mother, she never knew her father. Mother with hex of generalized anxiety and was verbally abusive, abused benzodiazepines, no substance hex for patient. No previous psychiatric treatment. Has one glass red wine with dinner. Sleeps 12-13 hrs.; appetite decreased. Has overactive bladder, untreated. Allergic to Zofran; complains of headaches, takes prn Tylenol, has diarrhea 2-3 times weekly, takes OTC Imodium. Symptom Media. (Producer). (2016). Training title 40 [Video]

Anxiety Disorder Case Study

Anxiety Disorder Case Study

Transcript of Video:

 

00:00:00TRANSCRIPT OF VIDEO FILE:

00:00:00______________________________________________________________________________

00:00:00BEGIN TRANSCRIPT:

00:00:00[sill.]

00:00:15[She nervously plays with her scarf as she breathes anxiously]

00:00:25OFF CAMERA Hello Mrs. Wieder. Are you ok? Do you want some water or something?

00:00:30MRS. WEIDRE I’m ok. I’m fine.

00:00:35OFF CAMERA, I understand you wanted to see me today.

00:00:40[She breathes anxiously]

00:00:40MRS. WEIDRE I just really needed to sit and talk.

00:00:40OFF CAMERA Well, tell me what’s wrong, what are you feeling?

00:00:50MRS. WEIDRE I’m just so… so unsure. I’m tired of being stuck in my house. I don’t like it.

00:01:00OFF CAMERA Stuck in your house? Do you have difficultly left your house?

00:01:05MRS. WEIDRE Yes. All the time.

00:01:05OFF CAMERA When do you go out?

00:01:10MRS. WEIDRE …maybe, once or twice.

00:01:15OFF CAMERA A Day?

00:01:15[She clutches her hands to her chest]

00:01:15MRS. WEIDRE A week. Tuesdays and Saturdays.

00:01:20OFF CAMERA Why Tuesday and Saturday?

00:01:30MRS. WEIDRE Because when my husband gets home, he can go with me.

00:01:35OFF CAMERA What do you do when you go out?

00:01:40MRS. WEIDRE I take walks.

00:01:40OFF CAMERA Where do you walk?

00:01:40MRS. WEIDRE I only go to the end of the block, and then I cross the street, and turn around, and I go back around the cul-de-sac. I’ll do those three times. [Losing breathe] No more, then I have to go back inside… I also go in my backyard. That’s usually okay.

00:02:15OFF CAMERA On the walks, why do you have to go back after three times? What happens?

00:02:20MRS. WEIDRE [She nervously looks around] I just can’t go any further.

00:02:25OFF CAMERA Is this a physical problem, knees or something?

00:02:30[She plays with her scarf]

00:02:30MRS. WEIDRE No. No. Well… maybe. I just can’t breathe if I’m out any longer.

00:02:40OFF CAMERA Oh, breathing?

00:02:40MRS. WEIDRE Yeah.

00:02:40OFF CAMERA What do you feel?

00:02:45MRS. WEIDRE [Her voice quivering] I’m just so frightened. Really, really scared. You don’t realize what it took for me to get here today. I really had to. I willed it. I closed my eyes, and my husband turned the radio up all the way as he drove. And then he led me into the building.

00:03:20OFF CAMERA Is there something that triggers this, anything in particular?

00:03:30MRS. WEIDRE I don’t like people. Maybe that’s it. I mean I can tolerate them. Ethan, the little boy next door, I’ll bake things for him and say hello. Sometimes, sometimes I watch him when his parents are gone. I mean I can be around people. Maybe that’s not that’s not what I meant.

00:04:00OFF CAMERA Ok, can you walk me through what happens when you do leave the house?

00:04:05MRS. WEIDRE I get shortness of breath, everything, the world just seems to close in on me, and everything gets feels really tight, the air in my body, my chest. I get dizzy. I don’t know what’s wrong… I could be sick. What is this?

00:04:30OFF CAMERA There can be many different causes for this. What is it that frightens you?

00:04:40MRS. WEIDRE [She’s short of breath] Death. I’m afraid to die.

00:04:45OFF CAMERA You’re afraid you might die?

00:04:50MRS. WEIDRE Yes. Among other things but that’s what pops into my head.

00:04:55OFF CAMERA Is their other stuff?

00:05:00[sill.]

00:05:05MRS. WEIDRE Cars go to fast. And there’s murders and rapes that I see on the news. And flashfloods. I just think it’s close, it’s safer to stay close to home.

00:05:15OFF CAMERA How long have you had this fear?

00:05:20MRS. WEIDRE I don’t really know.

00:05:20OFF CAMERA Do you know when it all started?

00:05:25MRS. WEIDRE I’m not sure.

00:05:30OFF CAMERA Do you know what started it?

00:05:30MRS. WEIDRE No.

00:05:35OFF CAMERA When was the last time you really ventured out for any length of time?

00:05:40MRS. WEIDRE Fifteen years.

00:05:45[She nervously shifts in her chair]

00:05:45OFF CAMERA That long. Is this the farthest you’ve been in fifteen years? What happened fifteen years ago?

00:06:00MRS. WEIDRE I don’t really know.

00:06:05OFF CAMERA There is nothing that happened to you personally that could have made you afraid of dying?

00:06:10MRS. WEIDRE I always was. My mother died the year before that. But it happened little by little. First it was planes. And then I couldn’t drive on the freeway, then I couldn’t drive at all, then errands, then it was going out… and soon… here I am.

00:06:40OFF CAMERA It must have taken you extraordinary courage to come here today. What finally brought you to see me?

00:06:50MRS. WEIDRE My grandson was born. But I couldn’t go and see him. I still haven’t seen him. My daughter gave birth last week and she’s not going to bring him to see me for several months and I don’t want to wait that long.

00:07:10OFF CAMERA You miss out.

00:07:15MRS. WEIDRE Yes! Of course, I do! My grandson is a thousand miles away and I can’t leave the God damned house.

00:07:25[sill.]

00:07:25END TRANSCRIPT

Anxiety Disorder Case Study

Assignment:

Incorporate the following into your responses in the template: Comprehensive Psychiatric Evaluation

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.
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.
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.).
References:

Anxiety Disorder Case Study

American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disorders Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?URL= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders

Med Easy. (2017). Anxiety, OCD, PTSD and related psychiatric disorders | USMLE & HomeLinks to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=-BwzQF9DTlY. Use APA referencing style.

December 18, 2023
December 18, 2023

Mood Disorders Treatment

ASSESSING, DIAGNOSING, AND TREATING ADULTS WITH MOOD DISORDERS
TO PREPARE
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)

Mood Disorders Treatment
Mood Disorders Treatment

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.). Use APA referencing style.