TO PREPARE:
(a) considering resources and the insights they provide about assessing, diagnosing, and treating mood disorders.
(b) Review the Focused SOAP NOTE TEMPLATE, which you will use to complete this Assignment. There is also a Focused SOAP note Examplar provided as a guide for Assignment expectations.
(c) Review the Case Study Interview Transcript of Ms. Petunia Park. You will use this case as the basis of this Assignment.
(d) Consider what history would be necessary to collect from this patient
(e) Consider what interview questions you need to ask the patient.
(f) Consider patient diagnostics missing from the interview transcript provided.
2. PROVIDER REVIEW OUTSIDE OF THE INTERVIEW:
(1) Temp 98.2, Pulse 90, Respiration 18, B/P 138/88
(2) Laboratory Data Available: Urine drug and Alcohol screen -Negative. CBC within normal ranges, CMP within normal range. Lipid panel within normal ranges. Prolactin level 8: TSH 6.3 (H)
THE ASSIGNMENT:
(a) 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 complaints and symptomatology to derive your differential diagnosis? What are the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? Their History of present illness (HPI), Past psychiatric history, Medication trial, and current medication, Psychotherapy or psychiatric diagnosis, Pertinent substance use, Family psychiatric/ substance use, social, and medical history, and Allergies.
Objective: What Observations did you make during the psychiatric assessment? Provide accurate documentation of the patient’s ROS for pertinent systems, Diagnostic tests, and their results.
ASSESSMENT: Discuss the patient’s mental status examination results. What was your differential diagnosis? Provide a minimum of three possible diagnoses with supporting evidence, listed in the order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rule 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 determinants 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.)
Provide at least Three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current and ( no more than 5 years old).
Please answer all parts of the assignment questions expectation with reflective critical analysis.
(4) Writer #33988, I will upload (a) The Case Study Interview Transcript of Ms. Petunia Park. which is the case you will use as the basis of this Assignment.(b)Also the Focused SOAP Note Template to also use to complete this Assignment and also a Focused SOAP Note Exemplar provided as a guide for this assignment expectation. Please provide at least four references.
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