NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
Subjective:
CC (chief complaint): Petunia Park states that she had used drugs in the past but stopped because she felt they were stifling her actual personality. She raises worries about how drugs may affect her general well-being and creativity: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template.
HPI: Petunia Park is a 28-year-old female who presents for psychiatric assessment based on medication noncompliance and fluctuating mood symptoms. She complains of feeling one or two a year with an excess amount of energy, decreased need for sleep, expanded creativity, agitation, talkativeness, and hypersexuality, each occurring for about a week. This is then preceded by low motivation, energy, and self-esteem. Petunia has a history of multiple psychiatric hospitalizations, having been hospitalized initially in her teenage years for insomnia and assumed auditory hallucinations.
Her most recent hospitalization was this spring. Her mental illness history is depression, anxiety, and potential bipolar disorder. She overdosed on Benadryl in 2017 but does not have any current suicidal ideation.
Her medication history is Zoloft, which resulted in insomnia and racing thoughts; Risperidone and Seroquel, both of which resulted in weight gain; and Klonopin, which made her feel sluggish. She recently stopped a medication that began with the letter “L” as it stifled her creativity.
Substance Current Use:
Petunia Park does not want to quit smoking, and she smokes one pack a day. She quit drinking alcohol when she was 19 and never drank again. She denies taking cocaine, methamphetamines, opioids, or synthetic drugs, and the only history of substances she has used is marijuana, which made her paranoid.
There is no history of seizures, blackouts, drug-induced hallucinations, or psychosis. She has also shut down rumors that she wants to leave and said she is not planning on going.
Medical History:
Petunia is presently receiving medication to treat her hypothyroidism. She expresses her opinion on whether or not she is now pregnant.
- Current Medications: She currently uses birth control for PCOS or polycystic ovarian syndrome.
- Allergies: No known food and drug allergy
- Reproductive Hx: She confirmed that she gets regular periods, with the most recent one occurring within the last month. She is sexually active and uses contraceptives to manage her PCOS. She has never been pregnant or had any childbirth experience.
ROS:
- GENERAL: No history of drastic weight loss, fever, or chills; inconsistent energy levels.
- HEENT: No issues with sight or hearing impairment.
- SKIN: No rashes or itching.
- CARDIOVASCULAR: No chest pain or palpitations.
- RESPIRATORY: Normal respiratory function, no shortness of breath.
- GASTROINTESTINAL: No complaints of nausea, vomiting, or diarrhea.
- GENITOURINARY: No issues; sexually active.
- NEUROLOGICAL: No seizures or weakness.
- MUSCULOSKELETAL: No complaints raised.
- HEMATOLOGIC: No concerns of bleeding or bruising.
- LYMPHATICS: No issues raised concerning lymph swelling.
- ENDOCRINOLOGIC: Hypothyroidism, managed with medication.
Objective:
Diagnostic results: Petunia Park’s vital signs are stable: temperature 98.2°F, pulse 90 BPM, respiratory rate 18 breaths/min, and blood pressure 138/88 mmHg. Urine drugs/alcohol, CBC, metabolic panel and lipid profile are all normal, and prolactin is 8. However, her TSH is elevated at 6.3, which indicates potential hypothyroidism issues that should be looked at.
Assessment:
Mental Status Examination:
Petunia Park is casually dressed, well-groomed, and cooperative during the interview. She speaks rapidly and with animation, her mood extremely expansive and a labile affect. Her thought process is circumstantial and tangential, making staying on the same subject difficult.
She denies any current suicidal or homicidal ideation, and there is no evidence of delusions. Right now, she does not report any hallucinations. She is alert and oriented to person, place, and time cognitively but shows impaired insight and judgment, which interfere with effective overall decision-making.
Diagnostic Impression:
- Bipolar I Disorder, Current Episode Hypomanic (ICD-10: F31.0)
The symptoms of Petunia Park are most in line with bipolar I disorder, current episode hypomanic. DSM-5-TR defines a hypomanic episode as a period of abnormally elevated, expansive, or irritable mood lasting at least four consecutive days and manifesting at least three symptoms among inflated energy, reduced need for sleep, talkativeness, flight of ideas, distractibility, and excessive engagement in activities (Jain & Mitra, 2023). Petunia’s episodes of high energy, decreased sleep, impulsiveness, and creativity match these criteria. Furthermore, the depressive episodes that subsequently follow also strongly support the diagnosis of bipolar I.
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- Critical Thinking Process
Petunia’s mood swings are episodic, with clear periods of hypomania and depressive episodes, which is more indicative of bipolar I disorder compared to other disorders, which encompass more chronic mood instability. The positive symptoms are the clear episodes of hypomanic and depressive episodes. The negative symptom is the fact that her mood swings are episodic, which is opposed to the pervasive emotional instability that occurs in other diagnoses, such as borderline personality disorder.
- Cyclothymic Disorder (ICD-10: F34.0)
Petunia’s mood swings ruled out cyclothymic disorder. DSM-5-TR criteria for cyclothymia call for periods of hypomanic symptoms and depressive symptoms of at least two years’ duration but not meeting the full criteria for hypomanic or depressive episodes (Bielecki & Gupta, 2022). Petunia has complete episodes of hypomania and depression that last more than four days, which are above the subthreshold criteria for cyclothymia. The positive symptoms are complete episodes of hypomania and depression, and the negative symptom is the absence of subthreshold symptoms.
- Borderline Personality Disorder (ICD-10: F60.3)
Borderline personality disorder (BPD) was also considered because of Petunia’s impulsivity and possible relationship instability. DSM-5-TR diagnostic criteria for BPD, however, indicate pervasive emotional instability, impulsivity, and unstable relationships, with symptoms evident in several situations (Chapman et al., 2021).
Petunia’s mood instability is episodic, with clear periods of hypomania and depression, as opposed to chronic emotional dysregulation. The episodic quality of the mood swings eliminated BPD in favor of bipolar I disorder. The positive symptoms are impulsivity and mood swings, and the negative symptom is the lack of pervasive instability typical of BPD.
Reflections:
As the patient relays, this case indicates medication nonadherence and attentive listening to the patient’s complaint. Ethical principles such as respect for persons, confidentiality, non-maleficence, and respect for the patient’s autonomy and imposing compliance simultaneously are involved. Family history, relationship history, childhood trauma, and numerous other sociological determinants factor into her psychiatric conditions.
It is required to intervene in her risky smoking and unsafe sex to encourage her healthy lifestyle. It is possible to offer the given technique in this situation as a treatment, allowing her to master her symptoms and remain creative.
Case Formulation and Treatment Plan:
Psychotherapy
Petunia Park will start cognitive behavioral therapy (CBT) to enhance her mood and medication compliance. Education about bipolar disorder, its nature, treatment suggestions, and the value of following treatment advice will also be imparted.
Pharmacologic Treatment
She will be prescribed Lithium 300mg PO BID, a first-line medication for the treatment of bipolar disorder. For her hypothyroidism, she will be maintained on Levothyroxine 25mcg PO daily (Eghtedari & Correa, 2023). Her TSH, renal function, and serum lithium level will be checked regularly to monitor her response to treatment.
Non-Pharmacologic Treatment
Petunia will be motivated to adopt good sleep hygiene, eat a balanced diet, and exercise daily. According to Kriakous et al. (2021), mindfulness-based stress reduction strategies can be suggested as an adjunct therapy.
Health Promotion Activity and Patient Education Strategy
The patient will be provided with smoking cessation counseling due to her smoking history to support long-term health gain. Also, she will be instructed in the use of mood stabilizers, side effects, and the need to stay on her prescribed regimen.
Follow-up
She will be followed up in two weeks to assess how she responds to the medication and identify whether any side effects need treating.
References
Bielecki, J. E., & Gupta, V. (2022). Cyclothymic disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/32491800/
Chapman, J., Jamil, R. T., & Fleisher, C. (2021). Borderline personality disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28613633/
Eghtedari, B., & Correa, R. (2023). Levothyroxine. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539808/
Jain, A., & Mitra, P. (2023). Bipolar disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558998/
Kriakous, S. A., Elliott, K. A., Lamers, C., & Owen, R. (2021). The effectiveness of mindfulness-based stress reduction on the psychological functioning of healthcare professionals: A systematic review. Mindfulness, 12(1), 1–28. https://doi.org/10.1007/s12671-020-01500-9
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Question 
Assessing, Diagnosing, and Treating Adults With Mood Disorders
Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.
In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.
To Prepare
- Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
- Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
- Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
- Consider what history would be necessary to collect from this patient.
- Consider what interview questions you would need to ask this patient.
- Consider patient diagnostics missing from the video:
- Provider Review outside of interview:
- Temp 98.2 Pulse 90 Respiration 18 B/P 138/88
- Laboratory 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)
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template
The Assignment
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.).
By Day 7 of Week 4
Submit your Focused SOAP Note.
Submission Information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK1Assgn+last name+first initial.
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Resources:
- Video, Case Study: Petunia Park.
- Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). WoltersKluwer.
- Chapter 8, “Mood Disorders”
- Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.
- Depressive and Bipolar Disorders: Crash Course Psychology #30