Focused SOAP Note and Patient Case Presentation<\/p>\n
Introduction
\nConsider the experiences you have had thus far, either in the healthcare workplace or at your practicum site. As you likely know, a nurse\u2019s job does not begin and end with one-to-one patient contact. It includes meetings, documentation, trainings, and collaboration. In particular, the nurse is a member of an interdisciplinary team and must use oral and written communication to inform others of a patient\u2019s status. A central skill of advanced practice nursing, then, is the ability to present a patient\u2019s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment.
\nDevelop a focused SOAP note on one of the patients you have examined in your clinical practicum. (40 years old female with Anxiety Disorder)
\nLearning Objectives
\nStudents will:<\/p>\n
\u2022\tAssess patients across the lifespan in mental health settings
\n\u2022\tFormulate differential diagnoses for patients across the lifespan in mental health settings
\n\u2022\tDevelop plans of care for patients across the lifespan in mental health settings
\n\u2022\tAdvocate health promotion and patient education strategies across the lifespan
\n\u2022\tDevelop a case study presentation based on a clinical patient<\/p>\n
Ace my homework – Write my paper – Online assignment help tutors – Discuss Subjective data:<\/p>\n
\u2022 Chief complaint<\/p>\n
\u2022 History of present illness (HPI)<\/p>\n
\u2022 Medications<\/p>\n
\u2022 Psychotherapy or previous
\npsychiatric diagnosis<\/p>\n
\u2022 Pertinent histories and\/or ROS
\nAccurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and\/or review of systems that would inform a differential diagnosis.<\/p>\n
Ace my homework – Write my paper – Online assignment help tutors – Discuss Objective data:<\/p>\n
\u2022 Physical exam documentation of systems pertinent to the chief complaint, HPI, and history<\/p>\n
\u2022 Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
\nAccurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.
\nAce my homework – Write my paper – Online assignment help tutors – Discuss results of Assessment:<\/p>\n
\u2022 Results of the mental status examination<\/p>\n
\u2022 Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient\u2019s symptoms
\nAccurately documents the results of the mental status exam.<\/p>\n
Presents at least three differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection. Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.<\/p>\n
Ace my homework – Write my paper – Online assignment help tutors – Discuss treatment Plan:<\/p>\n
\u2022 A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.
\nClearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.
\nReflect on this case. Ace my homework – Write my paper – Online assignment help tutors – Discuss what you learned and what you might do differently.
\nReflections are thorough, thoughtful, and demonstrate critical thinking.
\nFocused SOAP Note documentation
\nThe response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.
\nPresentation style
\nPresentation style is exceptionally clear, professional, and focused.<\/p>\n
Template to follow<\/p>\n
Focused SOAP Psychiatric Evaluation Template<\/p>\n
Subjective:
\nCC (chief complaint):
\nHPI:
\nSubstance Current Use:
\nMedical History:<\/p>\n
\u2022\tCurrent Medications:
\n\u2022\tAllergies:
\n\u2022\tReproductive Hx:
\nROS:
\n\u2022\tGENERAL:
\n\u2022\tHEENT:
\n\u2022\tSKIN:
\n\u2022\tCARDIOVASCULAR:
\n\u2022\tRESPIRATORY:
\n\u2022\tGASTROINTESTINAL:
\n\u2022\tGENITOURINARY:
\n\u2022\tNEUROLOGICAL:
\n\u2022\tMUSCULOSKELETAL:
\n\u2022\tHEMATOLOGIC:
\n\u2022\tLYMPHATICS:
\n\u2022\tENDOCRINOLOGIC:
\nObjective:
\nDiagnostic results:
\nAssessment:
\nMental Status Examination:
\nDiagnostic Impression:
\nReflections:
\nCase Formulation and Treatment Plan:<\/p>\n
References<\/p>\n
Anxiety Disorder
\nDate:
\nName:
\nInstitution:<\/p>\n
Anxiety Disorder
\nSubjective:
\nCC (chief complaint): \u201c I am always anxious\u201d
\nIHPI:
\nThe forty-year-old claim to be too anxious, and s require psychotherapy, and other medical advice to feel better. The patient complains of having anxiety attacks, which hinder her from carrying out her daily activities (Stein, and Sareen, 2015 – Research Paper Writing Help Service). Most of the time, the lady becomes anxious for no apparent reason, despite efforts to control the anxiety. The anxiety makes hinder her from attending a social gatherings, such as birthday parties. On the other hand, the patient requires medical advice to assist her in staying away from the negative feeling (Lamb,et,al.,2017).
\nSubstance Current Use:
\nThe patient has been using a drug known as Retinoid for managing a condition known as psoriasis. Also, the patient is under stress management medication, known as B-50 vitamin.
\nMedical History:
\nThe forty-year-old lady has been diagnosed with psoriasis, which is a skin condition. The skin condition is characterized by red patches with white scales accumulating on the lower back, scalp, and elbows. Due to the condition, the lady has been stressed as one of the impacts of psoriasis (Fleming, et,al.,2017).
\n\u2022 Current Medication:
\nNone
\n\u2022 Allergies:
\nDry air makes the patients skin flair more<\/p>\n
\u2022 Reproductive Hx:
\nThe patient is married and has no history of sexual health issues. The patient is also a mother of two children who are grown up.
\nROS:
\n\u2022 GENERAL: Show signs of acute distress
\n\u2022 HEENT: The head is filled with white patches and red pimples, eyes, nose, and throat.
\n\u2022 SKIN: the skin is red, pale, has cracks, and discoloration of the nails.
\n\u2022 CARDIOVASCULAR: no palpitation
\n\u2022 RESPIRATORY: no wheezing or shortness of breath
\n\u2022 GASTROINTESTINAL: No heartburn, diarrhea, or nausea.
\n\u2022 GENITOURINARY: No urinary urgency or frequency
\n\u2022 NEUROLOGICAL: the patient is not oriented
\n\u2022 MUSCULOSKELETAL: no muscle pain
\n\u2022 HEMATOLOGIC: the blood is in good condition no signs of infections or hematologic disease
\n\u2022 LYMPHATICS: good
\n\u2022 ENDOCRINOLOGIC: good
\nObjective:
\nDiagnostic results:
\nAnxiety disorder is caused by stress resulting from uncomfortability caused by psoriasis disease.
\nAssessment:
\nMental Status Examination: Motor: No psycho-motor retardation or any agitation
\nMood; no disturbances
\nBehavior: the patients are restless, do not maintain appropriate eye contact, although cooperative.
\nAppearance: The patient appears older than forty years, thin, and not so hygienic.
\nSpeech: The patient has a normal tone, fluent while speaking, and sound volume.
\nCognition: The patient has a good memory, does not fully pay attention, but fund of knowledge,
\njudgment, and impulse control: Good
\nDiagnostic Impression:
\nConstant worrying, which is difficult to control. The worrying is characterized by muscle tension, sleep disturbances, fatigue, restlessness, and irritability. The worrying, however, caused discomfort, and stress making it hard to engage in social occupations.
\nReflections:
\nI have learned that anxiety disorder is a mental health issue that makes a person worry, stressed and irritable. Also, I have learned that some diagnoses can lead to anxiety, such as psoriasis disease. I have also learned that before prescription, it is essential to find out current medication to avoid complications; when the medicine becomes incompatible Psychotherapy, and medication can work well in dealing with anxiety, hence it is essential to seek help in case of a mental health issue (Bandelow, Michaelis, and Wedekind, 2017).
\nCase Formulation and Treatment Plan:
\nI recommend the use of serotonin reuptake inhibitors (SSRIs) good for anxiety. An example of an SSRI is Paxil, which is very effective, especially for older people. The drug, however, assist in reducing symptoms of stress, and any discomfort caused that may lead to anxiety (Bandelow, Michaelis, and Wedekind, 2017). The patient should take the SSRIs daily together with B-50 for relieving stress. The patient should change her medication for psoriasis to taking methotrexate since her condition is severe (Bandelow, Michaelis, and Wedekind, 2017). I will prescribe the medication for purchases. I would recommend therapy, mostly group therapy, which would assist in dealing with anxiety. The medication and therapy will play an essential role in reducing exacerbation caused by stress and reducing skin flairs, which affect the ladies self-esteem, leading to anxiety. Occasionally, the patient should see a dermatologist manage the skin condition and a psychiatrist for psychotherapy to manage and treat anxiety disorder.<\/p>\n
References
\nBandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93.
\nFleming, P., Bai, J. W., Pratt, M., Sibbald, C., Lynde, C., & Gulliver, W. P. (2017). The prevalence of anxiety in patients with psoriasis: a systematic review of observational studies and clinical trials. Journal of the European Academy of Dermatology and Venereology, 31(5), 798-807.
\nLamb, R. C., Matcham, F., Turner, M. A., Rayner, L., Simpson, A., Hotopf, M., … & Smith, C. H. (2017). Screening for anxiety and depression in people with psoriasis: a cross\u2010sectional study in a tertiary referral setting. British Journal of Dermatology, 176(4), 1028-1034.
\nStein, M. B., & Sareen, J. (2015 – Research Paper Writing Help Service). Generalized anxiety disorder. New England Journal of Medicine, 373(21), 2059-2068.<\/p>\n","protected":false},"excerpt":{"rendered":"
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