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SOAP Note For Mood Disorders Discussion

SOAP Note For Mood Disorders Discussion

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.)SOAP Note For Mood Disorders Discussion.

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Patient particular’s

Name: Ms. Natalie Crew

Age: 17years

Gender: Female

Subjective Data

Chief complaint: “my mum is worried because I become moody every year around this time”

History of presenting complaint: Ms. Natalie is a 17years old female sent to the clinic due to her mum’s worry about mood changes. She says that she feels so down and she is not doing well in school. She is worried because she has suddenly changed her interest in the course work of special business program. Moreover, she finds it difficult to complete tasks. She states she has reduced concentration span, impaired memory, increased need for sleep, weight gain, feels miserable about herself, and finds her friends and the current season annoying. She denies hallucinations, delirium, and suicidal ideation.

Psychiatric history: the patient denies depression, anxiety, psychosis, and substance abuse disorder.

Substance use history: she denies the use of marijuana, alcohol, tobacco, cocaine, and other hard drugs.

Family history: she grew up with her parents and four siblings. She denies a family history of chronic diseases.

Social history: the patient is single. She was born and raised in New Orleans. She recently accelerated the high school business program. She is living in a specialty high school campus dormitory as a student and working part-time at a coffee shop.

Past medical and surgical history: the patient denies surgical procedures, hospital admission, previous chronic diseases, and transfusion. Her immunization schedule is up to date. SOAP Note For Mood Disorders Discussion

Allergies: she denies food and drug allergies

Review Of Systems

General: Ms. Natalie Crew denies headache, fatigue, weight loss, night sweats, chills and rigors, and fever.

HEENT: The patient denies headache, dizziness, running nose, nasal congestion, throat pain, neck swelling, ear ache, tearing, blurring of vision, and loss of hearing.

Respiratory system: the patient denies coughing, running nose, chest pain, wheezing, tachypnea, difficulties in breathing, sputum production, and respiratory distress.

Cardiovascular system: the patient denies chest pain, syncope, shortness of breath, palpitations, tachycardia, orthopnea, paroxysmal nocturnal dyspnea, dyspnea, and swelling of lower limbs.

Gastrointestinal system: the patient denies abdominal pain, reflux, heartburn, loss of appetite, nausea, vomiting, diarrhea, constipation, and GERD.

Genitourinary system: the patient denies dysuria, hematuria, polyuria, anuria, incontinence, urgency, per vaginal discharge, and itchiness.

Musculoskeletal system: the patient denies muscle pain, joint pain, muscle spasm, muscle weakness, and stiffness.

Neurological system: she denies facial droop, tingling sensation, muscle weakness, numbness of extremities, and sciatica.

Hematological system: she denies anemia, fever, bleeding tendencies, dizziness, and recurrent infections.

Endocrine system: the patient denies heat and cold intolerance, stretch marks, and fatigue.

Skin: she denies itchiness, rash, erythema, hypopigmentation, and hyperpigmentation.

Objective Data

General examination: The patient is alert, calm, and seems overweight. She has no pallor, jaundice, or cyanosis.

HEENT: the head is round with no mass, swelling, or scar. The eyes are clear and moist. The nose is intact without scars and erythema and the mucus membrane is moist. The ears have no scars, swelling, wax impaction, and discharge, the mouth is pink and moist with no swollen tonsil gland SOAP Note For Mood Disorders Discussion.

Respiratory system: the chest expands symmetrically when breathing. There is no intercostal resection, lower chest wall indrawing, and use of accessory muscles when breathing. There is no mass and scar on the chest wall. There is a resonant percussion note and vesicular breath sounds on auscultation. There are no rhonchi, stridor, or crackles.

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Cardiovascular system: the heart is at 5th ICS MCL. The peripheral pulses are present with normal volume, regular rhythm, and rate without bruits. The heart sounds S1 S2 is present without murmurs, parasternal heaves, and thrills.

Abdominal examination: the abdomen is round with a normal contour. The bowel sounds are present in the four quadrants and there is a tympanic percussion note. There is no shifting dullness and organ enlargement.

Neurological system: the patient is alert and oriented to time, place, and person. She can obey commands. She assumes an upright gait and posture. Her cerebellum functions are intact. The cranial nerves are all functional.

Diagnostic investigations: there are no specific tests that can confirm the diagnosis in this patient. However, some underlying diseases like sepsis, hypothyroidism, chronic kidney disease, liver failure, and substance abuse may alter mental function (Jacobson, et al, 2019)SOAP Note For Mood Disorders Discussion. Therefore, I would request various tests to rule out the cause of the disease. The tests include a complete blood count with differentials, thyroid function test, liver function test, renal function test, and blood and urine toxicology screen. According to Wang,  et al, (2019), screening tests specific to this patient are the PHQ-9 questionnaire of depression scale, Beck Depression Inventory, the young mania rating scale, and Assess MD adult depression assessment.

Assessment

Mental State Examination

The patient is alert and oriented to time, place, and person. She is neat for the occasion and weather. She has reduced gestures, does not maintain eye contact, and fidgets during the interview. She is in a low mood pessimist about the present and hopeless about the future. Her speech is slow with long pauses and has a low volume. Her concentration and memory are intact during the interview. Her thought process is congruent without hallucination and suicidal thoughts. Her judgment and insight are intact SOAP Note For Mood Disorders Discussion.

Differential Diagnoses

  • Hypomania bipolar F31.0
  • Major depressive mood disorder F32.9
  • Dysthymic mood disorder F34.1

Hypomania bipolar is a mental disorder presenting with low mood, hypersomnia, agitation,  fatigue, hopelessness, excessive guilt, loss of concentration, indecisiveness, and diminished interest or pleasure. These symptoms manifest after an episode of excitement, increased distractibility, diminished need for sleep, flamboyance, and inflated self-esteem (Carvalho, et al, 2020). Causes of hypomania bipolar are depression, genetics, stressful events, herbal supplements, and change in sleeping patterns. This is the primary diagnosis because the patient presents with low mood, loss of interest in her studies, irritability, excessive guilt, and inability to complete tasks. These symptoms occurred after a season of enjoying her studies, meeting her friends, and going out to the beach. The patient’s mood changes were due to seasonal changes from summer to winter. She prefers summer to winter because she can go to the beach.

Major depressive mood disorder is a mental illness characterized by agitation, mood changes, and irritability. These psychomotor changes affect social interactions and cognitive functions. According to the American psychiatric association DSM-5 criteria, the patient must present with loss of interest, hopelessness, suicidal ideation, fatigue, loss of memory, and impaired concentration (Vidal, et al, 2020)SOAP Note For Mood Disorders Discussion. The patient’s mood changes have been affected by performance, lost interest in her school work, and can hardly complete tasks. However, it is not the actual diagnosis because the patient denies suicidal ideation.

The dysthymic mood is a chronic depressive mood persisting from childhood. It presents with anger outbursts, sadness, loss of memory, inability to concentrate, suicidal attempts, and poor judgment (Carta, et al, 2019). This is not the actual diagnosis because the patient’s symptoms are acute and have no suicidal ideation.

Reflection

Assessing a patient with a mood disorder was initially challenging because it was hard to create rapport to share their problem. During the interview, the patient takes long pauses and has a slow speed, low tone, and low volume. In the future, I will establish a good patient rapport by ensuring there is a comfortable sitting position and the office maintains privacy. I will welcome the patient and begin catching up with them before asking about their problems. I will ensure the catchup is easy and interactive around their lives. Then I will select the appropriate words to ask the patient what is wrong with them. I will listen actively and maintain genuine gestures and cues. I will ask open-ended questions to allow the patient to express their concern SOAP Note For Mood Disorders Discussion.

Mood disorders are mental diseases because they disrupt the cognitive and behavioral functions of a patient. Therefore, these patients have a right to protection from harm, right to treatment, right to confidentiality, and right to informed consent (Sapthiang, et al, 2017). As a nurse, I will incorporate the ethical principles of consent, beneficence, and confidentiality when treating this patient. She is 17years, her insight and judgment are intact, and she is alert. I will obtain informed consent before treatment because she understands the course of the illness and can make the appropriate decision. The patient has a right to the confidentiality of her medical information and chooses who to disclose her information. She has the right to quality treatment to restore her functions and improve her quality of life. The patient is a full-time student working part-time, she will seek medical help to restore her functionality. Being a student, she is aware of mental instabilities and their impact. Moreover, she has a part-time job, therefore, she has income and social protection and can access healthcare services of decent quality SOAP Note For Mood Disorders Discussion.

References

Carta, M. G., Paribello, P., Nardi, A. E., & Preti, A. (2019). Current pharmacotherapeutic approaches for dysthymic disorder and persistent depressive disorder. Expert opinion on pharmacotherapy, 20(14), 1743-1754. https://doi.org/10.1080/14656566.2019.1637419

Jacobson, N.C., Weingarden, H. & Wilhelm, S. Digital biomarkers of mood disorders and symptom change. npj Digital Med 2, 3 (2019). https://doi.org/10.1038/s41746-019-0078-0

Sapthiang, S., Van Gordon, W. & Shonin, E. Mindfulness in Schools: a Health Promotion Approach to Improving Adolescent Mental Health. Int J Ment Health Addiction 17, 112–119 (2019). https://doi.org/10.1007/s11469-018-0001-y

Vidal, C., Lhaksampa, T., Miller, L., & Platt, R. (2020). Social media use and depression in adolescents: a scoping review. International Review of Psychiatry, 32(3), 235-253.

https://doi.org/10.1080/09540261.2020.1720623

Wang, Y. Y., Xu, D. D., Liu, R., Yang, Y., Grover, S., Ungvari, G. S., … & Xiang, Y. T. (2019). Comparison of the screening ability between the 32-item Hypomania Checklist (HCL-32) and the Mood Disorder Questionnaire (MDQ) for bipolar disorder: a meta-analysis and systematic review. Psychiatry Research, 273, 461-466.

https://doi.org/10.1016/j.psychres.2019.01.061

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66. https://www.nejm.org/doi/full/10.1056/NEJMra1906193 SOAP Note For Mood Disorders Discussion

INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY

If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignment in Weeks 4–10. After reviewing the full details of the rubric, you can use it as a guide.

In the Subjective section, provide:

  • Chief complaint
  • History of present illness (HPI)
  • Past psychiatric history
  • Medication trials and current medications
  • Psychotherapy or previous psychiatric diagnosis
  • Pertinent substance use, family psychiatric/substance use, social, and medical history
  • Allergies
  • ROS
  • Read rating descriptions to see the grading standards!

In the Objective section, provide:

  • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
  • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
  • Read rating descriptions to see the grading standards! SOAP Note For Mood Disorders Discussion

In the Assessment section, provide:

  • Results of the mental status examination, presented in paragraph form.
  • At least three differentials with supporting evidence. List them from top priority to least 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.
  • Read rating descriptions to see the grading standards!

Reflect on this case. Include: 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 taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.) SOAP Note For Mood Disorders Discussion

EXEMPLAR BEGINS HERE

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. First what is bringing the patient to your evaluation.  Then, include a PSYCHIATRIC REVIEW OF SYMPTOMS.  The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5-TR diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13. SOAP Note For Mood Disorders Discussion

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana)SOAP Note For Mood Disorders Discussion, and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)SOAP Note For Mood Disorders Discussion

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.

 

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe SOAP Note For Mood Disorders Discussion.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)SOAP Note For Mood Disorders Discussion.

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good SOAP Note For Mood Disorders Discussion .

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnostic impression selection. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

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Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.)SOAP Note For Mood Disorders Discussion.

References (move to begin on next page)

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting SOAP Note For Mood Disorders Discussion