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Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://waldenu.instructure.com Laborator Data Available: Urine d

adeptance

• 2 min read

Provider Review outside of interview:

Temp 98.2  Pulse  90 Respiration 18  B/P  138/88

Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://waldenu.instructure.com

Laborator Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)

 Develop a Focused SOAP Note, 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 symptomatology 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 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.
  • Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
  • Reflection notes: Reflect on this case. 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 that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

References:

 

  • Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer. 
    • Chapter 6, “Bipolar Disorders”
    • Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”
      • Section 2.9, “Depressive Disorders and Suicide in Children and Adolescents” (pp. 174-180)
      • Section 2.10, “Early-Onset Bipolar Disorder” (pp. 181-184)
    • Chapter 7, “Depressive Disorders”
    • Chapter 21, “Psychopharmacology”
    • Chapter 22, “Other Somatic Therapies”
  • Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.
    • Chapter 11, “Mood Disorders”

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