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Case Study For Depression Mood Assignment

Case Study For Depression Mood Assignment

PRAC WK3 Assignment 2: Focused SOAP Note and Patient Case Presentation

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Case Study For Depression Mood Assignment

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To Prepare
Review this week’s Learning Resources and consider the insights they provide. (IGNORE: I will create a self-recorded Kaltura video from this SOAP).
Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations..
The Assignment Case Study For Depression Mood Assignment
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
In your presentation:
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
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? Case Study For Depression Mood Assignment
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be Case Study For Depression Mood Assignment

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Subjective:

CC (chief complaint): Depressed mood and lack of sleep for two weeks.

HPI: The patient is a 36-year-old White female who presented to the clinic unaccompanied. She reports feeling a little depressed and having difficulty falling asleep for two weeks now. She reports that she first started experiencing feelings of hopelessness and sadness after the loss of her husband 6 months ago. At first, she thought this was normal and would go away but it only got worse when she could no longer concentrate at work. She also experienced agitation and irritability which made her lose her job as a waitress. Lately, she has been unable to sleep at night but sleeps a lot during the day. She has also lost interest in all the things she previously enjoyed. She says she has been using over-the-counter medications to help her sleep, which has been working but she would love to get her life back. She reports no suicidal ideations or feelings of self-harm.

She reports that she has no history of psychiatric conditions.

Substance Current Use: She reports occasional wine intake of two glasses with her meals. No history of cigarette smoking.

Social/Family History: the patient was married for 10 years, and her husband died six months before this visit. She lives in their family house. She has a daughter who is married and lives in a town nearby. She reports no history of cigarette use but occasionally takes alcohol. She reports no use of other illicit drugs. No family history of chronic illnesses Case Study For Depression Mood Assignment

Medical History:

 

  • Current Medications: She has been taking OTC Benadryl to help her sleep. She is not on any other medications
  • Allergies: No known food, drugs, or environmental allergies.
  • Reproductive Hx:

Attained menarche at 12 years,

She has a regular menstrual cycle of 28 days, with 4-5 bleeding days.

LMP- 28/08/2022. She is not on any contraceptives

She has one child, a daughter, who is married.

ROS:

  • GENERAL: She reports loss of appetite and fatigue. No recent changes in body weight, no fever
  • HEENT: She denies headache, dizziness, or head injury. No loss of vision, no eye swelling or reddening. Denies loss of hearing, ringing, bleeding from the ears, or any abnormal discharge. No nasal discharge, loss of smell, or nose bleeds. She denies any mouth sore, sore throat, or bleeding gums. She reports no difficulty or painful swallowing.
  • SKIN: No lacerations, no skin rashes/lesions, no excessive sweating
  • CARDIOVASCULAR: No palpitations, no dizziness, no orthopnea, no shortness of breath, no easy fatigability, and no chest pains.
  • RESPIRATORY: She reports no cough, no wheezing, no difficulty breathing or shortness of breath
  • GASTROINTESTINAL: No abdominal pains, no constipation, no diarrhea
  • GENITOURINARY: She denies any abnormal skin changes in the genital area, no lesions, or ulcerations. She denies any burning sensation or painful urination. No increased urgency or frequency of urination
  • NEUROLOGICAL: She denies headaches, memory loss, no numbness or tingling sensation in extremities, no abnormal muscle movements. No seizures or loss of consciousness
  • MUSCULOSKELETAL: She reports a feeling of general weakness for the past week. No pains or swellings of joints and extremities
  • HEMATOLOGIC: She reports no spontaneous bleeding or easy bruising. No anemia symptoms such as palpitations or dizziness
  • LYMPHATICS: The patient denies any limb swellings.
  • ENDOCRINOLOGIC: She denies excessive thirst, and sweating. No recent weight changes, no excessive facial hair. Case Study For Depression Mood Assignment

Objective:

General: The patient is alert and oriented to time, place, and person. She appears to be in fair general health and is dressed appropriately for the weather. No body odor.

Vital Signs: Temp: 97.6 °F, BP- 119/78 HR-72 beats /min, RR-18 breaths/min, O2 sat-99% on RA

HEENT:

Head: Normocephalic, normal hair distribution, no lacerations

Ears: Clean pinnae, no discharges, no otorrhea noted

Nose: Septum midline, no rhinorrhea, nasal mucosa pink and moist

Throat: Oral mucosa is pink and moist, tongue mobile, no lesions, tonsils present

Neck: No distended neck veins, no palpable lymph nodes

Cardiovascular: S1 S2 heard, no murmurs. Normal capillary refill, no edema, no cyanosis

Respiratory: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, stridor, grunting, or nasal flaring.

Neurological: A&O x4 to person, place, time, and situation. Able to follow complex and simple commands.  Memory intake able to recall events of the last 3 days. Able to recite the sequence of 5 words back in the order given. Perception of depth intact. Cranial nerves II -XII are grossly intact. Deep tendon reflexes were intact.  Able to distinguish soft, hard, blunt, and sharp sensations on upper and lower extremities as well as hot and cold temperatures.

Diagnostic results:

  1. Complete blood count normal
  2. Urea/Creatinine/Electrolytes normal
  3. LFTs normal

Assessment:

Mental Status Examination: (Mendez, 2022)

Appearance– The patient is in good health, clean, and well dressed. She is conscious and calm. Seated upright, No involuntary movements.

Behaviour– Dull facial expressions, does not maintain eye contact for long. She is calm

Speech- she makes a slow speech with long pauses in between, monosyllabic words, and the speech volume is low Case Study For Depression Mood Assignment

Mood– patient reports her mood as depressed;  Objectively she appears calm with a flat facial expression

Thought content/ perception– No suicidal ideations, no abnormal beliefs, no visual, auditory, or tactile hallucinations

Attention and concentration– she can count the days of the week backward.

Registration and memory– Recent, remote, and long-term memory intact

Abstract– she can interpret the meaning of simple proverbs

Insight– She understands that she has an illness that requires treatment

Judgment– Judgement is good

Diagnostic Impression:

  1. Major Depressive Disorder- The DSM-V criteria for MDD includes five or more symptoms of depressed mood, loss of interest or pleasure, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, low concentration, suicidal thoughts, and a feeling of guilt or worthlessness (Kaser & Sahakian, 2019). These symptoms should be a change from previous functioning and present for two weeks.

Differential diagnoses:

  1. Bipolar disorder-  bipolar disorder may present with symptoms of depressive episodes such as fatigue and sadness similar to MDD
  2. Borderline personality disorder- borderline personality disorder also presents with symptoms similar to MDD such as feelings of emptiness, depression, and anxiety (Greer & Joseph, 2019)Case Study For Depression Mood Assignment.
  3. Anxiety disorder- presents with agitation, restlessness, and anxiety

Reflections:

Case Formulation and Treatment Plan:

Medications and psychotherapy are often effective in the treatment of depression

  1. Pharmacotherapy- Antidepressants
  • Selective Serotonin Reuptake Inhibitors (SSRIs)- e.g Fluoxetine, are the first line of treatment for MDD because they are safer and have fewer side effects as compared to other antidepressants (Kaser & Sahakian, 2019).
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)- Venlafaxine; preferred in depressed patients with comorbid pain disorders.
  1. Psychotherapy- interpersonal therapy and cognitive behavioral therapy for behavior modification.

Follow-up;

  • Refer to a therapist for CBT
  • Review patient after a few weeks of treatment initiation to assess progress
  • Social determinants of health- Economic stability, social and community context, healthcare, and education access. These affect the quality of physical, emotional, and psychological health of an individual (Islam, 2019). The patient has good housing and social support from her daughter. This shows she has a good chance of recovery Kelley, 2020)Case Study For Depression Mood Assignment.

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References

Greer, T. L., & Joseph, J. K. (2019). Functional and psychosocial consequences of major depressive disorder. Cognitive Dimensions of Major Depressive Disorder, 1-14. https://doi.org/10.1093/med/9780198810940.003.0001

Islam, M. M. (2019). Social determinants of health and related inequalities: Confusion and implications. Frontiers in Public Health, 7. https://doi.org/10.3389/fpubh.2019.00011

Kaser, M., & Sahakian, B. J. (2019). Major depressive disorder is a disorder of cognition. Cognitive Dimensions of Major Depressive Disorder, 23-34. https://doi.org/10.1093/med/9780198810940.003.0003

Kelley, A. (2020). An overview of public health evaluation and the social determinants of health. Public Health Evaluation and the Social Determinants of Health, 1-18. https://doi.org/10.4324/9781003047810-1

Mendez, M. (2022). Overview of the mental status examination. The Mental Status Examination Handbook, 41-50. https://doi.org/10.1016/b978-0-323-69489-6.00005-x Case Study For Depression Mood Assignment