PRAC 6665 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation
Walden University PRAC 6665 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University PRAC 6665 Wk 9 Assignment 2: 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 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation
Whether one passes or fails an academic assignment such as the Walden University PRAC 6665 Wk 9 Assignment 2: 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 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation
The introduction for the Walden University PRAC 6665 Wk 9 Assignment 2: 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 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation
After the introduction, move into the main part of the PRAC 6665 Wk 9 Assignment 2: 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 Wk 9 Assignment 2: 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 Wk 9 Assignment 2: 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 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation
Subjective: “I have been experiencing sleep-related problems for the last two months.”
CC (chief complaint): A.X. is a 17-year-old male client that came to the unit with complaints of persistently experiencing poor quality and quantity of sleep for the last two months. The patient reported that he finds it difficult to fall asleep and maintain sleep. He also noted that his sleep duration is significantly reduced due to frequent night awakenings followed by failing to sleep. A.X. reported that the sleep problem was affecting significantly his academic performance. He finds himself dozing off in the afternoons at school due to a lack of adequate sleep from previous nights. He denied any use of sleep-enhancing medications.
HPI: The client reported that the issue started two months ago with worsening symptom and intensity.
Substance Current Use: The client denied any history of substance use or abuse.
Medical History: The client denied any history of hospitalization or surgeries.
- Current Medications: The client is currently not on any medication.
- Allergies: The client denied any history of food, drug, and environmental allergens.
- Reproductive Hx: The client denied any history of sexually transmit
PRAC 6665 Wk 9 Assignment 2 Focused SOAP Note and Patient Case Presentation ted infections. He is currently not dating. He denied any history of dysuria, urgency, and frequency.
ROS:
GENERAL: The patient is dressed appropriately, alert, oriented with no evidence of weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: The patient denied eye pain and discharge. He also denies hearing loss, sneezing, congestion, runny nose, or sore throat. He also denies difficulty in swallowing, lymphadenopathy, and difficulty in breathing. He denied headache and head trauma.
SKIN: The patient denies the presence of rash or itching.
CARDIOVASCULAR: The patient denies chest pain, chest pressure, or chest discomfort. He also denies palpitations or edema.
RESPIRATORY: He denies shortness of breath, cough, or sputum.
GASTROINTESTINAL: He denies anorexia, nausea, vomiting, or diarrhea. He also denies abdominal pain or blood.
GENITOURINARY: He denies burning on urination, increased urinary frequency and urgency, or changes in the color and smell of urine.
NEUROLOGICAL: He denies any history of dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. He also denies changes in bowel or bladder control.
MUSCULOSKELETAL: He denies muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: He denies anemia, bleeding, or bruising.
LYMPHATICS: He denies enlarged nodes. No history of splenectomy
PSYCHIATRIC: He denies any history of depression or anxiety.
ENDOCRINOLOGIC: He denies sweating, cold, or heat intolerance. No polyuria or polydipsia
ALLERGIES: No history of drug, food, or environmental allergies.
Objective:
Diagnostic results: A.X. is experiencing sleep problems. The diagnosis of sleep problems often relies on physical examinations and history taking. Psychiatric mental health nurse practitioners obtain comprehensive histories from their patients to guide in diagnosis. Laboratory investigations that include thyroid function tests and complete blood count may be performed to rule out any medical conditions that may be contributing to the problem. History taking and physical examination results were remarkable for a sleep disorder. Laboratory investigations were unremarkable.
Assessment:
Mental Status Examination: A.X is a male patient that appears appropriately dressed for the occasion. He does not have any evidence of weight loss. However, he appears fatigued due to a lack of sleep the previous night. He does not demonstrate any abnormal behaviors that include tics and tremors. He is oriented to self, place, and time. He denies illusions, delusions, and hallucinations. He also denies suicidal thoughts, plans, and attempts. His thought process is future-oriented.
Diagnostic Impression:
Episodic Insomnia: A.X’s primary diagnosis is insomnia. The patient has symptoms that align with those of insomnia, as stated in DSMV. According to DSMV, patients are diagnosed with insomnia if they present with complaints of dissatisfaction with sleep quality or quantity. The symptoms that accompany the dissatisfaction include difficulties in initiating sleep, maintaining sleep, and early-morning awakening that is followed by the inability to fall asleep thereafter. The duration of the sleep problem should be at least three months. The problem should also cause significant distress or impairment in functioning, including a decline in academic, social, and occupational functioning. Patients may also report difficulty in sleeping despite the presence of adequate opportunities for sleep (Ma et al., 2018). The sleep problem should not be attributed to other causes such as medication use, medical conditions, and substance abuse. Insomnia is further classified into persistent, episodic, or recurrent insomnia. Patients with persistent insomnia experience symptoms for a least 1-month and less than three months. Those with persistent insomnia experience symptoms for three months or longer while recurrent insomnia has two or more episodes within a year (de Zambotti et al., 2018). A.X. has symptoms that relate to the above, hence, insomnia being the primary diagnosis.
Depression: Depression is a secondary diagnosis that may be considered for A.X. According to DSMV, patients diagnosed with depression present with several symptoms. They include symptoms of depressed mood and lack of interest or pleasure. The depressive symptoms include having a depressed mood almost every day, weight loss or gain, insomnia or hyper-insomnia, psychomotor retardation or agitation, fatigue, worthlessness or guilt, decreased concentration, and suicidal thoughts, plants, or attempts (Maurer et al., 2018). Depression is the least likely diagnosis for A.X. due to the absence of depressive symptoms, weight changes, and lack of pleasure or interest.
Hypothyroidism: The other secondary diagnosis that may be considered for the patient is hypothyroidism. Patients with hypothyroidism may experience sleep-related problems. They may raise complaints that include insomnia, sleep lapses, or hyperinsomnia that occurs daily. Sleep disorders occur due to the involvement of the endocrine system in the disease (Chen et al., 2019). Laboratory investigations were unremarkable for the patient. Therefore, hypothyroidism is the least likely cause of the client’s sleep problems.
Reflections: I believe that the right approaches to diagnose the client with insomnia were utilized. Comprehensive history taking and physical examination guided the development of the diagnosis. One of the things that I will do if I experience similar care in the future is performing polysomnography. I will request a sleep study to be performed on the client to develop an accurate diagnosis of the sleep problem. Polysomnography will also help in initiating and adjusting the client’s treatment plan (Rundo & Downey III, 2019). The patient was not followed up. The next plan of action is scheduling the client for a follow-up review after four weeks to determine treatment effectiveness.
Case Formulation and Treatment Plan: A.X. was initiated on individual psychotherapy. He was educated on the importance of sleep hygiene habits. They included avoiding distractors during bedtime, caffeine, alcohol, or smoking, and taking heavy meals close to bedtime. The client was also educated about the importance of not engaging in strenuous activities close to bedtime and developing a sleep routine. He was educated about the importance of keeping a diary of effective strategies that helped him achieve better sleep. The strategies would be used to promote consistent improvement in sleep quality and quantity. The client was guided on the use of relaxation techniques and stimulus control therapy (Dewald-Kaufmann et al., 2019; Ma et al., 2018). The client was scheduled for a follow-up visit after four weeks to determine the effectiveness of the adopted treatment. Pharmacological treatments will be initiated should the client return with a history of worsening insomnia symptoms.
References
Chen, J., Hou, S., Li, X., & Yang, J. (2019). Management of Subclinical and Overt Hypothyroidism Following Hemithyroidectomy in Children and Adolescents: A Pilot Study. Frontiers in Pediatrics, 7. https://www.frontiersin.org/article/10.3389/fped.2019.00396
de Zambotti, M., Goldstone, A., Colrain, I. M., & Baker, F. C. (2018). Insomnia disorder in adolescence: Diagnosis, impact, and treatment. Sleep Medicine Reviews, 39, 12–24. https://doi.org/10.1016/j.smrv.2017.06.009
Dewald-Kaufmann, J., Bruin, E. de, & Michael, G. (2019). Cognitive Behavioral Therapy for Insomnia (CBT-i) in School-Aged Children and Adolescents. Sleep Medicine Clinics, 14(2), 155–165. https://doi.org/10.1016/j.jsmc.2019.02.002
Ma, Z.-R., Shi, L.-J., & Deng, M.-H. (2018). Efficacy of cognitive behavioral therapy in children and adolescents with insomnia: A systematic review and meta-analysis. Brazilian Journal of Medical and Biological Research, 51. https://doi.org/10.1590/1414-431X20187070
Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and Diagnosis. American Family Physician, 98(8), 508–515.
Rundo, J. V., & Downey III, R. (2019). Polysomnography. Handbook of Clinical Neurology, 160, 381–392.
Sample Answer for PRAC 6665 Wk 9 Assignment 2: Focused SOAP Note and Patient Case Presentation
Subjective:
CC (chief complaint): “I stop taking my drugs. They are not working.”
HPI: K.T is a 25-year-old Caucasian female who reported to the clinic with signs of mood disorder. She stopped taking her medication claiming that they were no longer effective. She confirms being an active rug user with a history of overdose and suicidal attempts. Her mother called the police on her as a result of her behavior. The patient was referred to a psychiatric unit for further evaluation. She reports hearing voices that affect her sleep at night. She claims that her sleeping pattern is also affected by her mood.
Past Psychiatric History:
- General Statement: Confirms a history of depression.
- Caregivers (if applicable): She lives with her mother who takes care of her.
- Hospitalizations: She has been hospitalized four times. The first hospitalization was as a result of a suicidal attempt, while the second was as a result of Bendery’s overdose. The other two hospitalizations were a result of defaulting in taking her medication.
- Medication trials: From her first diagnosis, she was prescribed Zoloft, risperidone, and Seroquel for six months. The drugs however failed to manage her mood symptoms, which made her stop taking them. She reports that Zoloft made her euphoric, Seroquel increased her heart rate and risperidone led to weight gain.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient claims that she has not experienced any withdrawal symptoms, after stopping to take her medication. She has no history of any other psychiatric disorder other than her present condition.
- Substance Current Use: As a result of mood issues and anxiety, the patient has been abusing several drugs. She confirms taking alcohol to manage her anxiety and depression. She also claims that she was taking marijuana but stopped since it was not working for her. Her substance use might have contributed to her mental disorder.
Family Psychiatric/Substance Use History: The patient has a family history of mood disorders and schizophrenia. Her brother was diagnosed with schizophrenia, while her father is an alcoholic who was jailed as a result of selling drugs. Her mother tried to commit suicide once, but she was lucky to survive.
Psychosocial History: The patient was born and raised in Georgia. She comes from a family of two. Her highest education level is high school, which she completed at the age of 18 years. She used to work at a local bookstore after high school, which she stopped as a result of her mood disorder. She currently lives with her mother, but sometimes stays with her boyfriend when her mother is not around. Her relationship with her boyfriend is normally on and off as per the mood she displays.
Medical History:
- Current Medications: Thyroid disorder. She takes thyroid Synthroid to manage her symptoms. She is currently on birth control pills as a result of being sexually active.
- Allergies: No allergies reported.
- Reproductive Hx: She confirms a regular menstrual cycle. She is sexually active with one boyfriend. She denies a family history of any reproductive disorders.
ROS:
- GENERAL: She appears healthy and well-nourished. Denies recent changes in weight, appetite, fatigue, or fever.
- HEENT: Head: No headache, trauma, or changes in hair distribution. Eyes: No double vision, excessive tearing, discharge, itchiness, or history of visual disorders. Ears: No pain, discharge, itchiness, tinnitus, or hearing problems. Nose: No congestions, running nose, or inflammation. Mouth/Throat: No bleeding gums, toothache, sore throat, or difficulties in swallowing.
- SKIN: warm with no rashes, bruises, eczema, lumps, or adenopathy.
- CARDIOVASCULAR: No chest pressure, pain, heart murmurs, or cyanosis.
- RESPIRATORY: No chest discomfort, breathing problems, cough, sneezing, or wheezing. GASTROINTESTINAL: No nausea, vomiting, diarrhea, constipation, changes in bowel movement, or hernia.
- GENITOURINARY: No changes in urine frequency, dysuria, polyuria, or pyuria. No abnormal discharge or painful sex.
- NEUROLOGICAL: No ataxia, headache, dizziness, or paresthesia.
- MUSCULOSKELETAL: No muscle or joint pain.
- HEMATOLOGIC: No history of nose bleeding, anemia, or any other blood disorder.
- LYMPHATICS: No history of splenectomy or lymphadenopathy.
- ENDOCRINOLOGIC: No polyphagia, disturbances in growth, or history of thyroid disease.
Objective:
Vital Signs: T- 98.9 BP- 97 Rr 22 150/88 Height 5’5 Wt. 135lbs
HEENT: Head is atraumatic and normocephalic. Pupils are round, equal, and reactive to light. No erythema or effusion on the tympanic membrane. No discharge or swelling was noted in the ear canals. The neck is supple with anterior cervical lymphadenopathy. The throat is clear with no swelling and exudates. Tonsils are not swollen.
Chest/lungs: Breathing sounds clear to auscultation
Heart: Regular heart rate and rhythm with no murmur or gallop.
Abdomen: non-distended abdomen, with normal bowel movement sound in all four quadrants.
Diagnostic results: Routine diagnostic tests such as complete blood count, white blood cells, LFTs, and lipid profile were ordered. X-ray and CT scans of the head were also ordered to rule out physical trauma as the cause of the patient’s symptoms (Kirkland et al., 2017). ECG was also performed to assess the extent of effect caused by previous psychotropic agents on the patient.
Assessment:
Mental Status Examination: The patient came in looking sad and tragic. She is well oriented in time, person and place. Her language ability is flowless all through the examination. She however displays incidences of serious sorrow. Her thought process is appropriate with perfect insight. Her affiliations are however sensible and unblemished (Zhang, & You, 2018). She denies indications of visual hallucinations but confirms auditory hallucinations at night. She also confirms sleeping problems which depend on her mood. Her judgment is reasonable, and she complains about working a lot. She confirms displaying anxiety and depression symptoms.
Diagnostic Impression:
- Major Depressive Disorder (MDD): This disorder is characterized by recurrent episodes of extreme sadness and diminished interest in routine daily activities. According to DSM-V diagnostic criteria, a patient can only qualify for this diagnosis when they display persistent and predominant mood disturbances that significantly affect their life because of diminished interest in routine daily activities which were previously interesting (Blackburn, Wilkins-Ho, & Wiese, 2017). The patient in the provided case study confirms being sad most of the time, and reduced interest in previously interesting things.
- Generalized Anxiety Disorder (GAD): Patients diagnosed with generalized anxiety disorder display irritable behaviour and diminished interest in routine daily activities. DSM-V diagnostic criteria require a patient to display excessive worry and anxiety for at least 6 months for the diagnosis of an anxiety disorder (Barateau et al., 2017). The patient displayed most of these symptoms, which makes GAD a probable diagnosis.
- Paranoid Personality Disorder: According to DSM-V, this disorder occurs in about 2.3 to 4.45 of adults which symptoms of chronic, and persistent distrust in other people such as family members (Pelletier et al., 2017). The patient claims that her relationship with her boyfriend is normally on and off, which might be a result of a personality disorder.
Reflections: The patient in the provided case study display symptoms of previously diagnosed depressive disorder. She however stopped taking her medication due to lack of effectiveness (Zhang et al., 2018). As a result, the PMHNP must conduct thorough therapeutic drug monitoring to find the most effective medication for the patient. She must also be educated on the importance of being compliant with the treatment therapy for a positive outcome.
Case Formulation and Treatment Plan:
Pharmacotherapy: Initiate 150mg Wellbutrin XL orally once a day (Zhang et al., 2018). Increase the dose to 300mg on the 4th day depending on the patient’s response.
Psychotherapy: Cognitive behavior therapy (CBT) is recommended among patients with mood disorders to help promote appropriate behavior and positive thinking (Kirkland 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 (Blackburn, Wilkins-Ho, & Wiese, 2017).
Health Promotion: Take part in physical exercise and consume a healthy diet to promote both physical and mental health.
Patient Education: The patient must be educated on the importance of the consistency of taking medication as prescribed to promote treatment outcomes.
Follow-up: The patient must report back to the clinic on day 4 for further evaluation of the treatment outcome and dose titration.
References
Barateau, L., Lopez, R., Franchi, J. A. M., & Dauvilliers, Y. (2017). Hypersomnolence, hypersomnia, and mood disorders. Current psychiatry reports, 19(2), 13. https://doi.org/10.1007/s11920-017-0763-0
Blackburn, P., Wilkins-Ho, M., & Wiese, B. S. (2017). Depression in older adults: Diagnosis and management. British Columbia Medical Journal, 59(3). DOI: 10.1001/jama.2017.5706.
Kirkland, J. L., Tchkonia, T., Zhu, Y., Niedernhofer, L. J., & Robbins, P. D. (2017). The clinical potential of senolytic drugs. Journal of the American Geriatrics Society, 65(10), 2297- 2301. https://doi.org/10.1111/jgs.1496
Pelletier, L., Shamila, S., Patten Scott, B., & Demers, A. (2017). Self-management of mood and/or anxiety disorders through physical activity/exercise. Health promotion and chronic disease prevention in Canada: research, policy and practice, 37(5), 27. DOI: 10.24095/hpcdp.37.5.03.
Zhang, L., Zhang, J., & You, Z. (2018). Switching of the microglial activation phenotype is a possible treatment for depressive disorder. Frontiers in cellular neuroscience, 12, 306. https://doi.org/10.3389/fncel.2018.00306