Unit 6-Clinical SOAP Note on schizoaffective disorder. Due 2-15-25.
Instructions
Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.
The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.
Note:
Grades of Incomplete on this assignment will result in a clinical failure.
All work should be original and submitted as a Word document unless otherwise indicated in the assignment instructions. ALL assignments need to be APA 7 format and accompanied title page in APA 7th edition format in order that the work would be properly identified for the student, the course, and the assignment. Work submitted without a title page will receive a grade of 0.
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Subjective
Patient Verification
Name: M. D.
DOB: 12/2/2004
Demographics: 20-year-old
Gender Identifier Note: Male
Chief Complaint (CC): “I’m struggling to stay focused at work and college, and I’m behind on assignments.”
HPI: M. D. is a 20-year old male, college student diagnosed with ADHD, predominantly inattentive type at age 18. Two months ago, he was started on methylphenidate (Ritalin) at an initial dose of 10 mg once daily. According to him, he experienced a mild improvement in his focus during the first few weeks of treatment but his distractibility, procrastination and completing assignments remain problematic. He often forgets normal instructions at his part time job as a retail assistant. M. D. has no major side effects from his medication, with stable sleep and appetite.
Pertinent History: M. D. occasionally feels overwhelmed and experiences low energy, impacting his productivity. He denies depressive episodes or irritability.
Sleep and Appetite: Sleep and appetite are stable.
Energy and Concentration: Decreased energy and concentration
Psychiatric Symptoms: Denies hallucinations, delusions, or panic attacks but describes chronic difficulty maintaining focus and staying organized.
SI/HI/AV: Denies suicidal ideation, homicidal ideation, or auditory/visual hallucinations.
Allergies: No known drug or food allergies (NKDFA).
Past Medical History: History of seasonal allergies, managed with loratadine PRN. No significant psychiatric or medical history.
Substance Use History: Occasional social alcohol use; denies tobacco or recreational drug use.
Family History: Father diagnosed with ADHD. Mother has mild anxiety disorder. No history of substance abuse in the family.
Social History: Lives in a dorm with roommates while pursuing a business degree. Works part-time at a retail store and is actively involved in his college’s entrepreneurship club
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Review of Systems (ROS)
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Constitutional: No fever, fatigue, or significant weight changes.
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Eyes: No vision changes.
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ENT: No hearing loss or throat pain.
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Cardiac: Denies chest pain, palpitations, or dizziness.
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Respiratory: Denies shortness of breath, wheezing, or chronic cough.
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GI: No nausea, vomiting, or changes in bowel habits
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GU: No dysuria or hematuria. Normal urinary habits.
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Musculoskeletal: Denies joint pain or stiffness.
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Skin: No rashes or lesions.
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Neurologic: Denies headaches or seizures. No tremors noted.
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Endocrine: No reports of excessive thirst or urination.
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Hematologic: No history of easy bruising or bleeding.
Objective
Vital Signs and Measurements
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Temp: 97.6°F
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BP: 131/86 mmHg
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HR: 78 bpm
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R (Respiratory Rate): 14 breaths/min
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O2 Saturation: 99% on room air
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Ht (Height): 188 cm
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Wt (Weight): 75.6 kg
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BMI: 20.8
Laboratory Findings
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LABS:
· Lab findings within normal limits (WNL).
· Toxicology Screen: Negative for all substances.
· Alcohol Screen: Negative.
· HCG: Not applicable (N/A).
Physical Exam:
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General Appearance: Patient is well-groomed, cooperative, and appears comfortable with no signs of acute distress.
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Skin: Skin is warm, dry, and free from rashes or lesions.
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HEENT: Eyes are clear with no conjunctival injection. No signs of nasal congestion or throat abnormalities.
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Cardiovascular: Heart rate and rhythm are regular with no murmurs or edema detected.
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Respiratory: Lungs are clear to auscultation on both sides with no wheezes, rales, or rhonchi present.
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GI: Abdomen is non-tender, no distension observed, and bowel sounds are normal.
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Musculoskeletal: Full range of motion with no joint swelling or tenderness noted.
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Neurologic: Patient is alert and oriented to person, place, time, and situation with no focal neurological deficits.
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Psychiatric: Cooperative with an appropriate affect, normal speech, and a linear thought process.
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Endocrine: No notable abnormalities observed.
MSE (Mental Status Exam):
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Appearance: Patient well-groomed, no acute distress.
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Behavior: Cooperative.
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Mood/Affect: Mildly anxious but appropriate for the situation.
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Speech: Normal rate and tone.
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Thought Process: Linear and goal-directed.
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Cognition: Intact but struggles with sustained attention during the session.
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Insight/Judgment: Fair.
Assessment
Diagnosis (DSM-5 and ICD-10 Codes):
ADHD, predominantly inattentive type
· DSM-5 Code: 314.00
· ICD-10 Code: F90.0
Differential Diagnoses:
Generalized Anxiety Disorder (GAD)
· Sometimes the symptoms of excessive worry and difficulty concentrating may blend with those of ADHD. However, while the differences between GAD and ADHD are significant, GAD is pervasive anxiety and restlessness whereas ADHD is chronic in attention with no appreciable anxiety (Koutsoklenis & Honkasilta, 2023).
· ICD-10 Code: F41.1
Learning Disorder
· Poor academic performance can be a learning disabilities symptom that’s similar to ADHD. But, unlike ADHD, learning disorders only pertain to academic tasks and do not affect other attention-related difficulties (Koutsoklenis & Honkasilta, 2023).
· ICD-10 Code: F81.9
Treatment Options
Pharmacotherapy:
· Initiate stimulant medication (e.g., methylphenidate or amphetamines) for ADHD management, starting with a low dose and adjusting as needed. Concerta 18 mg/day Increase does as indicated.
Psychotherapy:
· Cognitive-behavioral therapy (CBT) for ADHD to enhance organizational skills, reduce procrastination, and improve focus (Beyer et al., 2024).
· Psychoeducation and behavioral interventions to help with time management and emotional regulation.
Plan
1.
Pharmacologic Interventions:
· Increase methylphenidate dosage from 10 mg to 15 mg once daily (Beyer et al., 2024). Educate the patient on potential side effects, including appetite suppression and insomnia.
2.
Non-Pharmacologic Interventions:
· Recommend cognitive-behavioral therapy (CBT) to address procrastination and improve organizational skills (Beyer et al., 2024).
3.
Patient Education:
· Emphasize the importance of medication adherence and attending therapy sessions. Discuss lifestyle strategies, such as setting routines and breaking tasks into manageable steps
Safety Planning:
· Review signs of worsening symptoms (e.g., increased distractibility, restlessness) and when to seek further care..
4.
Follow-Up:
· Return to clinic in 2 weeks for medication and progress review.
Referrals:
· Referral to a therapist specializing in ADHD for CBT sessions.
Time spent counseling and coordinating care: 55 minutes
Total visit time: 80 minutes
Date: 1/29/2025
Time: 1:00 PM
References
Beyer, A. K., Beck, L., Pfeifer, S., Kuhnert, R., Hölling, H., Jans, T., … & Schlack, R. (2024). The consortium project INTEGRATE-ADHD-Comparison and integration of administrative and epidemiological ADHD diagnostic data by clinical assessment: study description and sample characteristics..
Koutsoklenis, A., & Honkasilta, J. (2023). ADHD in the DSM-5-TR: what has changed and what has not.
Frontiers in psychiatry,
13, 1064141.
Program Outcomes
1. Demonstrate critical thinking and holistic caring as an advanced practice
2. Analyze scientific literature for application to selected diagnoses and treatment plans.
3. Synthesize ethical principles into the management and evaluation of healthcare delivery concerns in culturally diverse care settings.
4. Articulate a personal philosophy and framework acknowledging professional and accrediting agency competencies relating to the role and scope of practice of the psychiatric mental health nurse practitioner.
5. Implement the role of the psychiatric mental health nurse practitioner in selected clinical settings.
Course Learning Objectives
By the end of this course, you will be able to:
1. Independently with mentor supervision, apply knowledge of chronic and acute psychiatric mental health disorders using the current edition of the Diagnostic and Statistical Manual for Mental Disorders diagnostic criteria to assess, diagnose and manage the patient populations across the lifespan including a focus on vulnerable populations at risk for mental health disorders.
2. Independently with mentor supervision, integrate complete mental health assessment, interview, history, and physical exam data collection with the knowledge of pathophysiology and psychopathology of psychiatric mental health disorders across the life span to form differential diagnoses and implement therapeutic, patient-centered treatment plans and interventions for patient populations across the lifespan.
3. Independently with mentor supervision, merge traditional and complementary pharmacological/non-pharmaceutical interventions into the treatment and management of psychiatric mental health disorders for patient populations across the lifespan.
4. Independently with mentor supervision, examine, evaluate, and demonstrate professional development in the role of the nurse practitioner in the diagnosis and management of health and wellness as well as acute and chronic psychiatric mental health disorders illnesses for patient populations across the lifespan as a member of an interprofessional team.
5. Independently with mentor supervision, integrate cultural, spiritual, and social competencies into therapeutic patient-centered treatment plans in connection with evidence-based findings to the diagnosis and management of individuals, groups, and families across the lifespan with acute, complex, and chronic psychiatric mental health disorders.
6. Independently with mentor supervision, analyze professional values and core ethical/legal standards into the practice of the Psychiatric Mental Health Nurse Practitioner role with relation to patient/staff safety, quality indicators, and health outcome improvement in the delivery of quality psychiatric mental health care to patients.
7. Identifies with mentor supervision, the highest level of professionalism and accountability for the PMHNP role for transition into clinical practice.
Resources
American Nurses Association & American Psychiatric Nurse Association. (2015).
Psychiatric–mental health nursing: Scope and standards of practice (2nd ed.) American Nurses Credentialing. ISBN-13: 978-1558105553 ISBN-10: 1558105557
American Psychiatric Association. (2022).
Diagnostic and statistical manual of mental disorders (5th ed.) text revision (DSM-5 TR). APA Press. ISBN 978-0890425763
Carlat, D. J. (2023).
The psychiatric interview (5th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971
Boland, R., Verduin, M., & Ruiz, P. (2022
) Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer. ISBN: 9781975145569
Stahl, S. M. (2022).
Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press. ISBN 978-1-108-97163-8
Bickley, L. (2016).
Bates’ Guide to Physical Examination and History-Taking (11th ed) [VitalSouce bookshelf version]. Lippincott Williams & Wilkins: ISBN 1609137620
Corey, G. (2016).
Theory and practice of counseling and psychotherapy (10th ed.). Cengage. ISBN: 9781305263727
Heldt, J. P., MD. (2017).
Memorable psychopharmacology. Create Space Independent Publishing Platform. ISBN-13: 978-1-535-28034-1
Johnson, K., & Vanderhoef, D. (2016).
Psychiatric mental health nurse practitioner review manual (4th ed.). American Nurses Association. ISBN: 978-1-935213-79-6
Stahl, S. M. (2020).
Prescriber’s guide: Stahl’s essential psychopharmacology (7th ed.). Cambridge University Press. ISBN 978-1108926010
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