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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Subjective:

CC (chief complaint): An 83-year-old female patient, NO, follows up for a psychiatric evaluation. Since her last visit, she has been generally better in mood and functioning, which she attributes to social activity and being around a friend. She learns that the medications she is taking to handle her symptoms are working for her: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template.

HPI: Her previous episodes of illness are generalized anxiety disorder, major depressive disorder with psychotic features, post-traumatic stress disorder, and drug-induced secondary Parkinsonism. She has followed her medication schedule as prescribed, being impeccable and not noticing any side effects. She says that she does not have hallucinations or delusions but admits that her anxiety does sometimes return in stressful situations. However, she is happy with her current treatment, though she is concerned that medications over a long period will have adverse long-term effects.

Substance Current Use: No current or past alcohol, tobacco, or recreational drug use; no illicit current drug use. No substance use disorder in the history.

Medical History: The patient has hypertension, hyperlipidemia, osteoarthritis, and no history of diabetes, stroke and seizures.

  • Current Medications:
    • Benztropine Mesylate 0.5 mg PO daily (for drug-induced Parkinsonism)
    • Escitalopram Oxalate (Lexapro) 10 mg PO daily (for depression and anxiety)
    • Risperidone 1 mg PO daily (for MDD with psychotic symptoms)
  • Allergies: No known drug, food, or environmental allergies
  • Reproductive Hx: The patient’s menopause occurred at the age of 51, and she has no history of gynecological cancers.

ROS:

  • GENERAL: No weight loss, fatigue, or fever.
  • HEENT: No headaches, blurred vision, or hearing loss.
  • SKIN: No rashes or lesions.
  • CARDIOVASCULAR: No chest pain, palpitations, or edema.
  • RESPIRATORY: No cough, dyspnea, or wheezing.
  • GASTROINTESTINAL: No nausea, vomiting, or abdominal pain.
  • GENITOURINARY: No dysuria, incontinence, or hematuria.
  • NEUROLOGICAL: No dizziness, seizures, or tremors beyond those induced by medication.
  • MUSCULOSKELETAL: Reports mild joint pain due to osteoarthritis.
  • HEMATOLOGIC: No bleeding or bruising.
  • LYMPHATICS: No enlarged lymph nodes.
  • ENDOCRINOLOGIC: No polyuria, polydipsia, or cold/heat intolerance.

Objective:

Diagnostic results: Recent CBC and metabolic panel results were within normal limits. An EKG from three months ago showed a normal sinus rhythm. No recent neuroimaging.

Assessment:

Mental Status Examination:

The patient is an 83-year-old female who is alert and oriented to person, place, time, and situation. She looks well dressed, as she might in the setting. During the session, she has good eye contact and a cooperative and pleasant demeanor. Her speech is clear and coherent, and neither are her rate, rhythm, or tone abnormal.

She’s had a better mood than the last visit and has managed to feel hopeful; she has been more engaged socially. Her affect is congruent with her mood, and she expresses all feelings. She is logical and goal-directed, with an organized thought process and no evidence of flight of ideas or tangential thinking. There are no delusions, paranoia, or obsessive thoughts, and she denies auditory or visual hallucinations.

Suicidal and homicidal ideation is absent. The mechanisms of perception used by her are undistorted or dissociated. She has intact memory for recent and remote events, concentration, and attention.

She knows a lot about the current condition of the condition and what benefits her medication has brought; she also knows how critical social engagement is to her mental health. She makes sound judgment decisions and can rationalize what is going on with her.

Diagnostic Impression:

  • Primary Diagnosis: Major Depressive Disorder (MDD), Recurrent, Severe with Psychotic Symptoms (F33.3)

The patient’s primary diagnosis is major depressive disorder, recurrent, severe with psychotic features. This is backed up by her history of persistent low mood, social withdrawal, and psychotic symptoms requiring antidepressants (Escitalopram) and antipsychotics (Risperidone) to control symptoms. As per the DSM 5 criteria, a patient is diagnosed with MDD if they suffer from at least five depressive symptoms, and these depressive symptoms must be present for more than two weeks duration, which include depressed mood, anhedonia, disturbance in sleep, fatigue, psychomotor agitation or retardation, feelings of worthlessness or difficulty concentrating, or thoughts of death, as indicated by Bains and Abdijadid (2023).

The severe type with psychotic features is diagnosed when delusions or hallucinations occur in a depressive interval. The matching data confirming the stabilization of the patient’s mood with medication adherence and social interaction proves there was no diminution of her illness, and she was not cured. This is the most appropriate diagnosis as she has a history of severe depressive periods as well as psychotic symptoms.

  • Generalized Anxiety Disorder (GAD) (F41.1)

Generalized anxiety disorder is the second differential diagnosis, as the patient has persistent worry and anxiety, but she says that her symptoms are improved with medication. Munir and Takov (2022) define GAD as excessive, uncontrollable worry that spans for at least six months, along with restlessness, fatigue, muscle tension, irritability, difficulty concentrating, and sleep disturbance. This patient has anxiety, but her anxiety is secondary to her depression. However, the primary issue she continues to struggle with is mood dysregulation as opposed to excessive or independent worry.

  • Post-Traumatic Stress Disorder (PTSD), Unspecified (F43.10)

Another possible diagnosis is post-traumatic stress disorder, unspecified, given the likelihood of a past traumatic event contributing to her anxiety and depressive symptoms. PTSD is defined by intrusive memories, avoidance behaviors, negative mood alterations, and hyperarousal symptoms following trauma (Mann et al., 2024). While PTSD may contribute to her emotional distress, her current symptoms are better explained by MDD with psychotic features. The lack of consistent re-experiencing symptoms (for example, flashbacks and nightmares) and avoidance behaviors make PTSD a less likely primary diagnosis.

  • Other Drug-Induced Secondary Parkinsonism (G21.19)

The fourth differential diagnosis is Other Drug-Induced Secondary Parkinsonism, as the patient is taking Risperidone, which is known to cause extrapyramidal symptoms such as tremors, rigidity, and bradykinesia. While she is currently on Benztropine to mitigate these effects, ongoing monitoring is necessary to differentiate medication-induced symptoms from primary neurodegenerative disorders such as Parkinson’s disease (Conn & Jankovic, 2024). Since her motor symptoms are directly linked to Risperidone use, this condition remains a relevant differential but is not the primary psychiatric concern.

Reflections:

If I could conduct the session again, I would further explore the patient’s history of trauma to assess its impact on her current symptoms and treatment response. While PTSD was considered a differential diagnosis, a more detailed discussion about past traumatic experiences, triggers, and coping mechanisms would provide deeper insight into her condition. Additionally, I would spend more time discussing the long-term risks of antipsychotic use in older adults and consider a gradual dose reduction of Risperidone if clinically appropriate. Extrapyramidal side effects, cognitive decline, and metabolic side effects must be monitored.

Her social life activities and medication adherence would continue to support symptom stability if a follow-up session was done. I would consider exposure to psychotherapy and reduction of dependence on pharmacologics, should her symptoms of mood and anxiety remain in control. If the symptoms worsen, an alternative treatment plan, for example, altering the antidepressant’s dose or switching to another evidence-based therapy, would be considered. In case I am unable to establish a follow-up, my next move would entail coordinating with her primary care provider and maintaining continuity in the care by telling her the importance of regular psychiatric follow-ups as a preventive measure against deterioration or relapse.

Case Formulation and Treatment Plan:

Case Formulation

An 83-year-old female presents with the diagnosis of MDD with psychotic features, GAD, and PTSD; she is currently well on Escitalopram, Risperidone, and Benztropine, and her mood improves and her functioning increases. The treatment plan focused on the maintenance of pharmacologic stability, psychotherapy, monitoring of the medical side effects, and support of social support to obtain better long-term mental health outcomes.

Treatment Plan

The patient’s treatment plan aims to manage her symptoms using evidence-based clinical guidelines, which include pharmacologic and non-pharmacologic interventions.

Pharmacologic Treatment

The patient reports stability in mood functioning; the current medication regimen will be maintained with Escitalopram (10 mg daily), Risperidone (1 mg daily), and Benztropine (0.5 mg daily). Although Escitalopram is an FDA-approved SSRI, it is still a first-line treatment for MDD with psychotic features due to its proven efficacy in the reduction of depressive symptoms (Bains & Abdijadid, 2023).

The atypical antipsychotic Risperidone is used adjunctively to treat past psychotic symptoms and to prevent relapse. Antipsychotics, however, have risks of metabolic syndrome and extrapyramidal symptoms with long-term use in older adults. Tardive dyskinesia, weight gain, and sedation must be monitored, and in future visits, even if symptoms are stable, the dose may be reduced gradually.

Alternative and Adjunctive Treatments

In addition to pharmacologic therapy, cognitive behavioral therapy (CBT) is advised to build up coping mechanisms and limit long-term medication dependence. As indicated by Chand et al. (2023), CBT is effective as an adjunctive therapy in reducing depressive and anxiety symptoms. Promotion of emotional well-being and cognitive function will be achieved through lifestyle modifications, such as physical activity and structured social engagement.

Follow-Up and Referrals

Treatment response, medication tolerance, and mental status stability will be followed up in four weeks with a scheduled appointment. Metabolic markers (fasting glucose, lipid profile) and motor symptoms (AIMS to assess extrapyramidal symptoms) will also be monitored (Bains & Abdijadid, 2023). For example, the patient is educated on medication adherence, side effects of the drug, and relapse prevention strategies. As there remains the possibility of ongoing relapse, given the ongoing symptoms, referral to psychotherapy for emotional support, cognitive restructuring and structured and pragmatic reasons is strongly encouraged.

Social Determinant of Health (Healthy People 2030)

Social isolation is a critical social determinant of health that impacts mental well-being in older adults, according to Healthy People 2030 (Office of Disease Prevention and Health Promotion, 2024). Encouraging community engagement activities, peer support groups, and volunteer programs will help enhance social connectedness and emotional resilience.

Health Promotion and Patient Education

A key health promotion activity will focus on fall prevention and cognitive stimulation strategies, as older adults on psychotropic medications are at increased risk for falls and cognitive decline. According to Bhattad and Pacifico (2022), patient education will emphasize the importance of medication adherence, avoiding sudden discontinuation, and engaging in structured daily activities to reduce mental health disparities and improve overall quality of life.

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

 

Date: ________________________

References

Bains, N., & Abdijadid, S. (2023). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Bhattad, P., & Pacifico, L. (2022). Empowering patients: Promoting patient education and health literacy. Cureus, 14(7), e27336. https://doi.org/10.7759/cureus.27336

Chand, S. P., Kuckel, D. P., Huecker, M. R. (2023, May 23). Cognitive behavior therapy. PubMed. https://pubmed.ncbi.nlm.nih.gov/29261869/

Conn, H., & Jankovic, J. (2024). Drug-induced Parkinsonism: Diagnosis and treatment. Expert Opinion on Drug Safety, 1–11. https://doi.org/10.1080/14740338.2024.2418950

Mann, S. K., Marwaha, R. & Torrico, T. J. (2024). Posttraumatic stress disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559129/

Munir, S., & Takov, V. (2022). Generalized anxiety disorder. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

Office of Disease Prevention and Health Promotion. (2024). Healthy People 2030. Health.gov. https://odphp.health.gov/healthypeople

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Question

Focused SOAP Note and Patient Case Presentation, Part 1

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.

To Prepare

  • Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
  • 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.

Please Note:

  • All SOAP notes must be signed, by your Preceptor. Note: Electronic signatures are not accepted.
  • When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of the completed assignment signed by your Preceptor.
  • You must submit your SOAP note using Turnitin. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
  • Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
  • Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
  • Ensure that you have the appropriate lighting and equipment to record the presentation.

    NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

    NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

The 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:

  • Dress professionally and present yourself in a professional manner.
  • Display your photo ID at the start of the video when you introduce yourself.
  • 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?
    • 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.

By Day 7 of Week 3

  • Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of completed assignment signed by your Preceptor.

submission information – Part 1: Video Submission

To submit your video response entry:

  • Click on Start Assignment near the top of the page.
  • Next, click Text Entry and then click the Embed Kaltura Media button.
  • Select your recorded video under My Media.
  • Check the box for the End-User License Agreement and select Submit Assignment for review.

submission information – Part 2: Focused SOAP Note Submission
To submit Part 2 of this Assignment, click on the following link:

  • Week 3 Assignment 2, Part 2
Client’s Notes:
  • Hello below is the patient for this case study .
    • NO is an 83-year-old female. A/O. Maintains eye contact. Speech is clear. Thought process intact.
      reports an overall improvement in mood and functioning, attributing this to spending time with a friend and engaging in social activities. She confirms that her medications are effective. The mental status examination shows she is healthy, engaged, and oriented. The plan includes continuing her current medication regimen, scheduling a follow-up appointment, and reviewing recent lab results at the next visit.

      • (F41.1) Generalized anxiety disorder
      • (F33.3) Major depressive disorder, recurrent, severe with psychotic symptoms
      • (G21.19) Other drug-induced secondary parkinsonism
      • (F43.10) Post-traumatic stress disorder, unspecified
      • Benztropine Mesylate 0.5 MG Oral Tablet
      • Escitalopram Oxalate (Lexapro) 10 MG Oral Tablet
      • Risperidone (risperiDONE) 1 MG Oral Tablet

Resources: