Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation
Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.
- 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, and each page must be initialed 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 each page that is initialled and signed by your Preceptor.
- You must submit your SOAP note using SafeAssign. 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.
Record yourself presenting the complex case study for your clinical patient. 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 patient 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: What was your plan for psychotherapy? What was 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. Be sure to include at least one health promotion activity and one patient education strategy.
- Reflection notes: What would you do differently with this patient if you could conduct the session over? 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.
Required Readings (click to expand/reduce)
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
- Chapter 28, “Assessing Neurocognitive Disorders (Dementia and Delirium)”
Expert Answer and Explanation
CC (chief complaint): “They want to kill me but people do not believe me. I can even hear them talk.”
HPI: JW is a 45-years-old male of Caucasian origin who came to the healthcare facility complaining of auditory and visual hallucinations. The patient has not been prescribed any medications at the moment until screening and testing are done. He complains that he has been seeing people around his home and hearing them planning his death.
She has been reporting hallucinations for the past six weeks or so. He was accompanied by his wife to the office. The wife noted that the patient has been showing catatonic behavior for the past weeks. She narrated that the patient sometimes grabs his gun and speaks to himself by saying that he will kill them before they kill him.
He has also been spotted echoing words as if he is repeating someone else’s words. The wife argued that when the client is not experiencing hallucinations, he experiences a depressed mood by not eating or wanting to be near anybody. When he is moody, he wants to be isolated and away from the world. The wife noted that the symptoms have pushed him away from his work and family. He was given leave to go and sought himself out.
Substance Current Use: The patient has a history of taking drugs. He reports using illicit drugs such as cocaine and meth. However, he denies using alcohol or cigarettes.
Medical History: He was diagnosed with hypertension but stopped taking medications noting that “they” want to kill him using medications.
- Current Medications: He is not on any medications at the moment.
- Allergies:No allergies.
- Reproductive Hx:He has not been able to engage in sexual activities in the past seven months.
- GENERAL: Wife reports weight loss. The client reports fatigue and weakness on some occasions. Denies fever or chills.
- HEENT: Eyes: No eye diseases or abnormalities. Ears, Nose, Throat: He denies hearing loss or infections. He denies a runny nose, sore throat, congestion, or sneezing.
- SKIN: No rash.
- CARDIOVASCULAR: No chest pressure, edema or palpitations, chest discomfort, or chest pressure.
- RESPIRATORY: No difficulty breathing, sputum, or cough.
- GASTROINTESTINAL: No abdominal pain, diarrhea, vomiting, nausea, or anorexia.
- GENITOURINARY: No odd color, hesitancy, odor, urgency, or burning during urination.
- NEUROLOGICAL: No tingling or numbness of the legs or fingers. No dizziness, headache, ataxia, paralysis, or bowel problems.
- MUSCULOSKELETAL: No stiffness or pain in the joints and muscles.
- No muscle, back pain, joint pain, or stiffness.
- HEMATOLOGIC: No anemia, clotting abnormalities, or abnormal hematologic status.
- LYMPHATICS: No enlarged nodes.
- ENDOCRINOLOGIC: Denies polydipsia, cold, sweating, polyuria, or heat problems.
Physical Exam: Temp 36, BP 137/90, Ht. 6’2, Wt. 145lbs, P 78, RR 18.
- HEENT: Head: Face is symmetrical. Cranial nerves V and VII around the head are intact. He can move facial muscles at will. The shape of the head is rounded and there are no involuntary muscle movements.Eyes: Cornea, conjunctiva, lacrimal system, anterior chamber, and pupils are intact. The eye is not painful or red. Vision intact. Lacerations positions normal. Ears: Hearing intact. No discharge, swelling, or redness in the ear. Nose: Mucosa membrane intact. Inspection of internal and external nose structures shows no abnormalities. Nasal passage intact. Throat: No swelling or redness in the throat.
- SKIN: Normal color and moisture. Normal finger and toenails to palpation. Skin turgor normal and no lesions.
- CARDIOVASCULAR: No arteriovenous malformations (AVMs), tenderness, shuts, or varicosities during observation of the peripheral veins. No murmur head on auscultation. No thrill. The height of the neck veins is proportional to right atrial pressure. The cardiac cycle properly reflects waveforms. Normal heart rhythm.
- RESPIRATORY: Percussion revealed that the patient’s lungs have no fluid. Palpation shows no pulmonary consolidation. No wheezes or crackles. Chest walls are intact with no swelling. No chest pain during palpation.
- The Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms (SANS and SAPS): The tools were used to measure negative and positive symptoms in the patient because he is showing signs of schizoaffective disorder (Kumari et al., 2017). Both tools showed that the patient has schizoaffective disorder.
- Electroencephalography (EEG): This test has been ordered. According to Tito et al. (2019), EEG in patients with the schizoaffective disorder often shows slowing of left frontotemporal with sparse paroxysms.
CT Scan: CT scan has also been ordered. The results of the scan will be used to rule out other medical problems mimicking psychotic symptoms.
Mental Status Examination:
The patient is well-dressed and his clothes fit the weather of the day. He answers questions correctly but sometimes shifts his attention to people he claims he sees or hears. His level of consciousness is clouded. Eye contact is direct on some occasions and furtive on others. Speech is clear and denies racing thoughts. He has flat expressions and moods. Affect is consistent will mood.
He has hallucinations and delusional thinking. He has seen and heard things other people could not see or hear. He shows a pessimistic attitude and is sometimes hostile. He views his illness as a nonpsychiatric and is a help-rejecting complainer. His memory is intact and denies homicidal or suicidal thoughts.
- Schizoaffective Disorder DSM-5 295.70 (F25.) Primary diagnosis
- Bipolar II Disorder DSM-5 296.89 (F31.81)
- Bipolar I Disorder DSM-5 296
The first and primary diagnosis for this case is schizoaffective disorder. Peterson et al. (2019) reported that schizoaffective disorder causes both psychotic and mood symptoms such as hallucinations and flat mood. The Diagnostic and Statistical Manual of Mental Disorder further explains criteria that should be considered when diagnosing patients with schizoaffective disorder.
According to American Psychiatric Association (2013), a person with schizoaffective disorder must meet Criterion A for schizophrenia which comprises two or more of the following symptoms; hallucinations, delusions, catatonic behavior, disorganized speech, and negative symptoms. The patient has delusions, negative symptoms, delusions, and catatonic behavior.
The DSM-5 also reports that a patient with schizoaffective should also have depression or mania and hallucinations and delusions for more than two weeks. The patient has all the symptoms making the disease the primary diagnosis.
The second diagnosis is bipolar II disorder. According to Duffy et al. (2020), bipolar II is a mood disorder that makes one experience hypomania and depression. The disorder has been included in the diagnosis because the patient has depression. However, it is a secondary disorder because the patient does not have hypomania episodes instead, he has psychotic symptoms.
The last diagnosis is bipolar I disorder. The disorder is known for mania and depressive episodes (Lima et al., 2018). However, it is a secondary disorder because the patient has hallucinations and delusions which are not signs of the disease.
I agree with the preceptor’s assessment and diagnostic impression. She has used DSM-5 to support her basis for including the disorders in the diagnosis. One of the things I have learned in the case is that schizoaffective disorder is difficult to diagnose because it shares symptoms with major psychotic and mood disorders. Therefore, if given a chance to work on the case again, I would screen the patient for mood disorders to confirm that he is not suffering from any mood disorder.
One of the ethical issues I should consider when treating this client is respect for persons. I should respect the client by not discriminating and rejecting him due to his mental health challenges. I should make the patient feel safe while in my care. Another consideration is justice. I should ensure that I practice justice when dealing with the client.
Case Formulation and Treatment Plan:
The patient has schizoaffective disorder. Therefore, I recommend that she be prescribed Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter. This medication has been selected because it can be well tolerated and can improve the symptoms of the client (Hargarter et al., 2018).
The authors noted that patients with schizoaffective disorder who took this medication reported no side effects. The medication has been selected because it can be used to treat patients on a long-term basis (Zhao et al., 2017). The authors reported that the medication has no side effects when used on a long-term basis. Invega Sustenna does not lead to relapse (Weiden et al., 2017).
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorder, ed 5. APA Press.
Duffy, A., Carlson, G., Dubicka, B., & Hillegers, M. H. J. (2020). Pre-pubertal bipolar disorder: origins and current status of the controversy. International Journal of Bipolar Disorders, 8(1), 1-10. https://journalbipolardisorders.springeropen.com/articles/10.1186/s40345-020-00185-2
Hargarter, L., Lahaye, M., Cherubin, P., Lambert, M., Swarz, M., Joldygulov, G., … & Schreiner, A. (2018). Treatment response and tolerability with once-monthly paliperidone palmitate initiated shortly after hospital admission in patients with schizophrenia. The World Journal of Biological Psychiatry, 19(sup3), S147-S157. http://dx.doi.org/10.1080/15622975.2017.1315176
Kumari, S., Malik, M., Florival, C., Manalai, P., & Sonje, S. (2017). An assessment of five (PANSS, SAPS, SANS, NSA-16, CGI-SCH) commonly used symptoms rating scales in schizophrenia and comparison to newer scales (CAINS, BNSS). Journal of Addiction Research & Therapy, 8(3), 324. https://doi.org/10.4172/2155-6105.1000324
Lima, I. M., Peckham, A. D., & Johnson, S. L. (2018). Cognitive deficits in bipolar disorders: Implications for emotion. Clinical Psychology Review, 59, 126-136. https://www.sciencedirect.com/science/article/pii/S0272735817300211
Peterson, D. L., Webb, C. A., Keeley, J. W., Gaebel, W., Zielasek, J., Rebello, T. J., … & Reed, G. M. (2019). The reliability and clinical utility of ICD-11 schizoaffective disorder: A field trial. Schizophrenia Research, 208, 235-241. https://doi.org/10.1016/j.schres.2019.02.011
Tito, E., Knapp, B., Bucca, A., & Espiridion, E. D. (2019). A case report of schizoaffective disorder with pseudoseizures in a 42-year-old male. Cureus, 11(6). https://www.psychiatrist.com/pcc/schizophrenia/temporal-lobe-epilepsy-mimicking-schizoaffective-disorder/
Weiden, P. J., Kim, E., Bermak, J., Turkoz, I., Gopal, S., & Berwaerts, J. (2017). Does half-life matter after antipsychotic discontinuation? A relapse comparison in schizophrenia with 3 different formulations of paliperidone. The Journal of Clinical Psychiatry, 78(7), 0-0. https://doi.org/10.4088/JCP.16m11308
Zhao, J., Li, L., Shi, J., Li, Y., Xu, X., Li, K., … & Lu, H. (2017). Safety and efficacy of paliperidone palmitate 1-month formulation in Chinese patients with schizophrenia: a 25-week, open-label, multicenter, Phase IV study. Neuropsychiatric Disease and Treatment. https://psycnet.apa.org/record/2017-34085-001
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INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused SOAP Note 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. After reviewing 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
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!
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 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.
- 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!), 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 FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression.
You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
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 medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.
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 follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment?
What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), 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.
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.
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.
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
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.
Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. 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?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males).
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care.
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.