PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation

Walden University PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation

Whether one passes or fails an academic assignment such as the Walden University PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation

The introduction for the Walden University PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation

After the introduction, move into the main part of the PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation

Patient Information

Initials: P.L

Age: 54 years old

Gender: Female

Race: Caucasian

Subjective:

CC (chief complaint): “Psychiatric evaluation.”

HPI: P.L is a 54-year-old female patient who was accompanied by her sister to the psychiatric clinic as a result of strange behaviors. Her sister claims that the patient has been hearing sounds of people watching her across the window. She also reports that people on television are talking to her. She is very cautious, and if even afraid to eat as she believes that people on the television will pop out of the screen and poison her food. Additional symptoms include nightmares which affect her sleep. She denies suicidal ideation or potential harm to herself or others.

Past Psychiatric History:

PRAC 6665 Assignment 2 WEEK 7 Focused SOAP Note and Patient Case Presentation

General Statement: Hospitalized at the age of 20 years due to psychiatric disorder. She has been on and off antipsychotics.
Caregivers (if applicable): She stays with her mother and sister.
Hospitalizations: Reports a history of hospitalization at the age of 20 years.
Medication trials: The patient was previously on Thorazine and Haldol, which she disliked how they made her feel. Seroquel was then introduced, which was effective, but the patient was inconsistent with taking the drug.
Psychotherapy or Previous Psychiatric Diagnosis: None specified.

Substance Current Use: Reports smoking tobacco, approximately 3 packs every day. She also confirms taking alcohol. Denies taking marijuana or any other drug of abuse.

Family Psychiatric/Substance Use History: Mother with a history of anxiety disorder, while the father with a history of paranoid schizophrenia, Father was diagnosed with paranoid schizophrenia.

Psychosocial History: The patient lies together with her sister and mother. She is unable to work as a result of her mental condition, which affected her highest level of education being the 10^th grade.

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Medical History: Currently managing diabetes. She also confirms having a fatty liver.

Current Medications: Metformin 500mg twice daily.
Allergies: No reported allergies

Reproductive Hx: The patient denies ever being married. She confirms menopause at age of 45 years. No history of reproductive complications.

ROS:

GENERAL: No fever, general body weakness, changes in body weight, fatigue, nausea, or vomiting.
PRAC 6665 Assignment 2 WEEK 7 Focused SOAP Note and Patient Case Presentation
HEENT: Head: No headache or trauma. Eyes: No tearing, discharge, blurred vision, or redness. Ears: No discharge, tinnitus, or itchiness. Nose: No congestions or running nose. Throat: No sore throat, tonsillitis, or swallowing difficulties.
SKIN: Intact with no rashes, hives, eczema, or itchiness.
CARDIOVASCULAR: No palpitations, dyspnea, edema, cyanosis, or chest pressure.
RESPIRATORY: No shortness of breath, wheezing, coughing, chest congestion, or sneezing.
GASTROINTESTINAL: No changes in bowel movement, nausea, vomiting, diarrhea, constipation, abdominal tenderness, or hernia.
GENITOURINARY: No dysuria, nocturia, discharge, urgency, or painful urination.
NEUROLOGICAL: NO headache, loss of consciousness, or vision changes.
MUSCULOSKELETAL: Full range of movement of joints with no pain, or inflammation.
HEMATOLOGIC: No bleeding problems or prolonged healing of wounds.
LYMPHATICS: No lymphedema
ENDOCRINOLOGIC: No excessive thirst, polyuria, or polydipsia.

Objective:

Diagnostic results: For a general assessment of the patient’s health, routine blood works like WBC, RBC and CBC were ordered. A drug test of the urine and blood was also ordered to assess for substance use disorders. Organ function tests such as LFTs and RFTs were also ordered to assess the effects of the psychotropic agents on the patient’s liver and renal function. A CT scan of the head and X-Ray are also necessary to rule out physical trauma as the reason behind the patient’s condition. Additional diagnostic tests include Calgary Depression Scale for Schizophrenia, PANSS, Clinical Global Impression-Schizophrenia (CGI-SCH), SAPS test, Rorschach (inkblot) test, and SANS test (Lewine & Hart, 2020).

Assessment:

Mental Status Examination: The patient walks into the room, in age-appropriate and clean clothes. She seems quite confused and avoids eye contact. However, her orientation in person, time, and place are intact. She displays poor judgment and odd beliefs like her life is in danger. She is unable to maintain the same topic during the interview. Her short-term memory is quite shoddy, but her long-term memory is intact. She displays a flat affect. Her thought process is inconsistent, as she will give different answers to the same question. She displays signs of depression, anxiety, hallucination, and delirium. She denies suicidal ideation or potential harm to herself or others.

Diagnostic Impression:

Schizophrenia Spectrum and Other Psychotic Disorders: Schizophrenic patients tend to display characteristics that suggest that they have lost contact with reality. Common symptoms include abnormal behaviors, visual or auditory hallucination, delusion, and disorganized thought processes. The DSM-V diagnostic criteria for this disorder requires the patient to display at least one symptom, from each of the two groups of symptoms (Addington et al., 2017). The first group of symptoms entails disorganized thought processes and speech, hallucination, and delirium, while the second group involves catatonic symptoms such as stupor, mutism, catalepsy, or negativism. The patient displayed both positive and negative symptoms which qualify for this diagnosis.
Bipolar I Disorder with psychotic features: Patients with this disorder tend to have manic episodes, which are associated with psychotic features such as delusion and hallucination. The DSM-V diagnostic criteria require patients to present with at least 3 of the following manic symptoms such as inflated self-esteem, reduced sleep, easily distracted, racing thoughts, irritability, and increased psychomotor agitation (Tasic et al., 2019). The patient must also present with at least one psychotic feature such as hallucination, or delusion to qualify for this diagnosis. The patient displayed psychotic symptoms, with no manic episodes, which disqualifies this diagnosis.
Delusional Disorder: In most cases, delusion is a symptom of other psychotic conditions. However, according to DSM-V, patients who display delusion only, and no other psychotic symptoms, for at least one month, qualifies for this diagnosis (Lewine, & Hart, 2020). However, the present patient displayed both delusion and hallucination among other symptoms. As such, she cannot qualify for this diagnosis.

Case Formulation and Treatment Plan:

Pharmacotherapy: Initiate 300mg of quetiapine (Rx) Extended-release on day one. Titrate the dose upwards by 25-50 mg per day to an optimal maintenance dose of between 400 to 800 mg once daily while observing patient outcome (Remington et al., 2017). This drug is effective in the management of schizoaffective symptoms and had already displayed great tolerance and adherence with the patient. The extended-release formulation will also help reduce the frequency of administration, hence promoting compliance.

Psychotherapy: Cognitive behavior therapy (CBT) is recommended among patients with schizophrenia to help promote appropriate behavior and positive thinking (Stijažiü et al., 2017).

Alternative therapy: The patient can also engage in Assertive community treatment (ACT), coordinated specialty care (CSC), self-help groups, or social skills training (Lewine, & Hart, 2020).

Health Promotion: Take part in physical exercise and consume a healthy diet to promote both physical and mental health (Stijažiü et al., 2017).

Patient Education: The patient must be educated on the importance of the consistency of taking medication as prescribed to promote treatment outcomes (Stijažiü et al., 2017).

Follow-up: The patient must report back to the clinic after 4 weeks for further evaluation of the treatment outcome so that necessary changes can be made to the treatment plan.

Reflections: The patient information provided is limited in making the required changes in the patient medication based on the severity of her condition. Both the subjective and objective portions of patient history suggest a diagnosis of schizophrenia. However, concerning her previous treatment approaches, some information is missing concerning the drug-specific side effects encountered, and the level of effectiveness of the psychotropic agents used. As such, it is necessary to talk to the patient informant more concerning her previous treatment to make sure that the current treatment plan does not display similar results. Consequently, the PMHNP must promote the health and well-being of the patient and prevent harm. As such, the next intervention will entail using both pharmacological agents which displayed great effectiveness with no harm to the patient, and psychotherapy, to promote patient’s compliance and treatment outcome (Remington et al., 2017).

References

Addington, D., Abidi, S., Garcia-Ortega, I., Honer, W. G., & Ismail, Z. (2017). Canadian guidelines for the assessment and diagnosis of patients with schizophrenia spectrum and other psychotic disorders. The Canadian Journal of Psychiatry, 62(9), 594-603. https://doi.org/10.1177/0706743717719899

Lewine, R., & Hart, M. (2020). Schizophrenia spectrum and other psychotic disorders. In Handbook of Clinical Neurology (Vol. 175, pp. 315-333). Elsevier. https://doi.org/10.1016/b978-0-444-64123-6.00022-9

Remington, G., Addington, D., Honer, W., Ismail, Z., Raedler, T., & Teehan, M. (2017). Guidelines for the pharmacotherapy of schizophrenia in adults. The Canadian Journal of Psychiatry, 62(9), 604-616. https://doi.org/10.1177/0706743717720448

Stijažiü, D., Jendrižko, T., & Biožina, S. M. (2017). Guidelines for individual and group psychodynamic psychotherapy for the treatment of persons diagnosed with psychosis and/or schizophrenia. Psychiatria Danubina, 29(3), 432-440. PMID: 28953804

Tasic, L., Larcerda, A. L., Pontes, J. G., da Costa, T. B., Nani, J. V., Martins, L. G., … & Hayashi, M. A. F. (2019). Peripheral biomarkers allow differential diagnosis between schizophrenia and bipolar disorder. Journal of psychiatric research, 119, 67-75. https://doi.org/10.1016/j.jpsychires.2019.09.009

Sample Answer 2 for PRAC 6665 Assignment 2 WEEK 7: Focused SOAP Note and Patient Case Presentation

Subjective:

CC (chief complaint): “heroin addiction”

HPI: T.L is a 17-year-old female Caucasian patient who was brought to the psychiatric clinic with her mother for her heroin addiction. The patient reports that she has been taking heroin for two years now, about 9 to 13 stamp bags each day. She was advised to consider rehabilitation but was reluctant. Currently, she reports symptoms of poor insight, hopelessness, depression, low self-esteem, and low self-worth. As a young girl, she was abused sexually by her uncle. She confirms taking marijuana from the age of 12 years, then pain pills, and currently cocaine. She has a history of PTSD and confirms self-injurious behavior, as she has cuttings on her inner upper arm. The patient reports that sometimes she trades sex for drugs. Hep c test results were positive. the patient denies suicidality.

Substance Current Use: The patient started taking marijuana at the age of 12 to counter the negative thoughts of being assaulted sexually by her uncle. She then moved to pain pills. For the past two years, she confirms using heroin, about 9 to 13 stamps daily. The patient denies drinking alcohol or use of any other illicit drug of abuse.

Family History of Substance Use: The patient’s father passed on about 10 years ago from an opioid overdose. Her mother was diagnosed with alcohol use disorder.

Medical History: Reports a history of post-traumatic stress disorder and self-injurious behavior.

Current Medications: Denies taking any medication at the moment.
Allergies: Reports no known food, drug, or environmental allergies.

Reproductive Hx: Heterosexual, and sexually active with multiple sex partners. Trades sex for drugs. Hep C positive. No history of HIV. Reports regular menses.

ROS:

GENERAL: Appears sharp and alert. No recent changes in body weight, fatigue, chills, fever, dizziness, reduced appetite, or lethargy.
HEENT: Head: denies headache. Even distribution of hair. No signs of injury or trauma. Eyes: No redness, excessive tearing, itchiness, polyploidy, or pain. Ears: No tinnitus, hearing loss, inflammation, itchiness, or exudates. Nose & Throat: No congestion, sinus problems, bleeding nose, running nose, inflammation, or itchiness. No sore throat, swallowing difficulties, or bleeding gums.
SKIN: Warm but somehow dry. No lesions, bruises, lumps, redness, inflammation, or eczema.
CARDIOVASCULAR: No palpitations, murmurs, chest tightness, cyanosis, syncope, arrhythmias, or hypertension.
RESPIRATORY: No running nose, congestion, breathing difficulties, sneezing, wheezing, cough, sputum production, asthma, or chest discomfort.
GASTROINTESTINAL: No tenderness, hernia, abdominal distension, diarrhea, constipation, nausea, or vomiting.
GENITOURINARY: No urgency, frequency, or burning sensation when urination or incontinence. Reports regular menses, with normal vaginal discharge.
NEUROLOGICAL: No ataxia, headache, heat or cold intolerance, reduced appetite, paresthesia, or dizziness.
MUSCULOSKELETAL: No muscle or joint tenderness, stiffness, or inflammation. Confirm full range of movement in both lower and upper extremities.
HEMATOLOGIC: Denies easily bruising, bleeding gums, nose bleeding, anemia, or any other hematological disorder.
LYMPHATICS: No lymphadenopathy or splenectomy.
ENDOCRINOLOGIC: Denies hypothyroidism, hyperthyroidism, polyphagia, polyuria, or polydipsia.

Objective:

Vital Signs: T 99.4, BP 139/86, HR 99, R 19, OS 99%, Ht. 68, Wt. 189.6.

Diagnostic results: Hepatitis C test was taken, revealing positive results. HIV and STD tests were also ordered. Urine and blood screening for drugs are ordered to determine the variety of drugs the patient is using. Kidney function tests and liver function tests are ordered to assess the impact of the drugs the patient has been taking on these organs. Routine blood work was also ordered including, a complete blood count, comprehensive metabolic panel, lipid profile, C reactive protein level, and AIC test. To promote the development of differential diagnosis, the following screening tools were utilized NIDA Modified Alcohol, Smoking, and Substance Involvement Screening (NM ASSIST), Drug Abuse Screen Test, and Posttraumatic Stress Disorder Checklist (PCL-5) (Upadhyay et al., 2022).

Assessment:

Mental Status Examination: The 17-year-old female patient walked into the examination room with great confidence in age-appropriate casual clothes. She displayed appropriate orientation in time place and person. She is cooperative during the interview with appropriate eye contact. Her speech is quite pressured but in regular tone and volume. Her insight is poor. Her thought process is appropriate for her age. Her mood is somehow sad. Her affect is congruent with her sad mood. Her memory is intact. Reports nightmares, flashbacks, and self-injurious activities. Denies suicidal ideation or hallucinations.

Diagnostic Impression:

Substance Use Disorder/Post-traumatic stress disorder (SUD/PTSD): The patient presents with a history of sexual abuse at a young age which contributed to her use of drugs. She has a history of PTSD and currently presents to the clinic for heroin addiction. She meets the DSM-V diagnostic criteria for PTSD with comorbid SUD, with additional symptoms such as poor insight, hopelessness, depression, low self-esteem, and low self-worth (Upadhyay et al., 2021).
Substance-Induced Depressive Disorder: According to DSM-V, patients who qualify for this diagnosis present with persistent and prominent low mood, with significantly reduced interest in activities that were previously enjoyable (Revadigar & Gupta, 2022). Depression is usually difficult to control. The patient is positive for poor insight, hopelessness, depression, low self-esteem, and low self-worth. The patient also reports using heroin for the past 2 years, which suggests that the depression symptoms are due to substance use.
Major Depressive Disorder (MDD): The patient presents with poor insight, hopelessness, depression, low self-esteem, and low self-worth which are indications of MDD as outlined by the DSM-V (Alang, 2018). She however presents with additional symptoms of PTSD and substance use, which disqualifies MDD as the primary diagnosis.

Reflections: The information provided suggests that the patient is struggling with PTSD and heroin addiction. She has been on treatment for PTSD, but currently, her mother is mainly concerned with her addiction which is getting worse. The PMHNP did an excellent job interviewing the patient to obtain the necessary information supporting this diagnosis. However, the patient’s school teacher would also be a great historian to provide more information regarding the patient’s behavior at school and how she is coping with her symptoms. The patient being 17 years is considered a minor, hence giving the mother legal responsibility of making health decisions on her behalf (Upadhyay et al., 2021). As such, the patient’s mother should be adequately informed about her daughter’s diagnosis and available treatment options. The clinician must also respect the patient’s autonomy when it comes to choosing which treatment option to go with.

Case Formulation and Treatment Plan:

Pharmacological Intervention: Start the patient with Sublocade injection every month to manage the heroin addiction (Rosic et al., 2021). To help with the patient’s PTSD symptoms, it will be necessary to administer 25mg of sertraline orally at bedtime. The dose of sertraline may be titrated at intervals of 25mg per day and increased weekly to attain an optimal dose, without exceeding the maximum dose of 200mg/day as per the patient’s tolerance and treatment outcome.

Non-Pharmacological Intervention: Rehabilitation and detoxification are considered the most effective adjunct to substance use. The patient will also need to attend group therapy for addiction and PTSD (Upadhyay et al., 2021). Cognitive behavioral therapy is considered an alternative therapy.

Health Promotion: Encourage the patient to promote her mental health through meditation and exercise (Revadigar & Gupta, 2022). Getting enough rest and sleep will also help reduce the depression associated with PTSD.

Patient Education: The patient needs to be educated on the importance of taking the medication as prescribed to exhibit optimal benefit and positive therapeutic outcomes (Rosic et al., 2021).

Follow-up: The patient needs to report back to the clinic after 4 weeks, for a second dose of Sublocade and evaluation of the treatment outcome. Necessary regimen adjustments will be made based on the patient’s feedback.

References

Alang, S. (2018). Contrasting depression among African Americans and major depressive disorder in the DSM-V. Journal of Public Mental Health, 17(1), 11–19. https://doi.org/10.1108/jpmh-12-2016-0061

Revadigar, N., & Gupta, V. (2022). Substance-Induced Mood Disorders. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/32310347/

Rosic, T., Au, V. Y. O., Worster, A., Marsh, D. C., Thabane, L., & Samaan, Z. (2021). Trauma and post-traumatic stress disorder in patients treated for opioid use disorder: findings from a 12-month cohort study. BJPsych Open, 7(4), e138. https://doi.org/10.1192/bjo.2021.971

Upadhyay, J., Verrico, C. D., Cay, M., Kodele, S., Yammine, L., Koob, G. F., & Schreiber, R. (2021). Neurocircuitry basis of the opioid use disorder–post-traumatic stress disorder comorbid state: conceptual analyses using a dimensional framework. The Lancet Psychiatry. https://doi.org/10.1016/s2215-0366(21)00008-0

Upadhyay, J., Verrico, C. D., Cay, M., Kodele, S., Yammine, L., Koob, G. F., & Schreiber, R. (2022). Continuing the conversation around opioid use disorder and post-traumatic stress disorder comorbidity. The Lancet Psychiatry, 9(8), e37–e38. https://doi.org/10.1016/S2215-0366(22)00234-6