Answered You can buy a ready-made answer or pick a professional tutor to order an original one.
Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-s FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1 Psychiatric notes are a way to reflect on you
Normal 0 false false false EN-US X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-s
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.
Please see the information provided and fill in the HILIGHTED missing information.
- Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
- 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. (total of 3 differential diagnoses for this part with one to include unspecified psychosis)
- Reflections: 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!), social determinates of health, 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.
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 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.
- @
- 3866 orders completed
- ANSWER
-
Tutor has posted answer for $20.00. See answer's preview
********* ******** Evaluation ***** Complaint: ** ****** unsure **** happened ** ****** ** *** **** **** *********** ** ** * *********** ********* **** ****** ******** ******** **** jail ***** ***** ******** for ****** ************ ********* *** not ***** ***** ***** ************ *** client ** here *** * psychiatric evaluation *** ****** *** **** ** the ******* ** *** local Police ********** *** ********** ****** Emergency ******* ***** (ECO) reporting ****** ****** delusions Client put **** in ***** ** ***** ********* **** *** ***** *** *************** ******* **** ****** ****** alcohol *** ****** ******* *** *** ** *************** **** ** *** * ************ ********** ** *** ****** unsure ** ********* ** amount used *** ****** **** *** ****** **** first ********** **** this ********* *** **** **** ******** ****** **** ****** * ***** ******** *** of * ** ***** ** ********** My ****** ******* ******* ** age ** ****** **** *** ****** a time ** ********** and decline *** ************** ******** *** ****** **** ***** to ********* ***** *** ******** ** disclose *** ******* ****** Urine *** ******** *** amphetamines cocaine *** ************ The ****** ******** ** elaborate ** ***** No withdrawal ******** *************** History: *************** ********** radiculopathy· ******* Medications: Suboxone ******* *** *** film ** BID for ************* Gabapentin ****** ** TID for neuropathy ******* 5 ** *** ** for ********* ******** ****** ** *********** ***** ***** **** ******* at night for ******** *********** ****** ** ** ***** PO for ******* ********* ******* ** 600 ** *** *** * days *** **** ******** Klonopin 1 mg ** *** for ******* *** Haldol * ** ** or ** every * ***** *** *** agitation ******** ** ** ** or ** ***** 6 ***** *** *** *** ******** ** mg ** ***** * ***** *** ******* ********* *** mg PO ***** * ***** *** for musculoskeletal **** *** ********* ** ** ** ** HS PRN for insomnia· ********** ********* ** food *** ************* *********** ************ Hx: ******* ****** **** erectile *********** ****** ***** ** ** ** Sildenafil 50 mg as ****** ****** ** ************ ************ ******** *** of contraceptivesROS:· ******** ***** mildly disheveled ** ***** ****** or ******* ** ****** ** weight· ****** **** ************* ****** pinpoint ********* ***** * mm ** redness ****** ****** ** nystagmus ** complaints of ******* loss ** ******** ** **** nasal ****** ****** **** ** ******** ** ********** ** soreness hoarseness or ******* SKIN: skin warm *** *** ****** **** scattered ******** to *** patient with ******** ******* ******* *************** ******* ****** ** ***** **** ** ********** no murmurs ** edema ** his of implanted ********* RESPIRATORY: ** *********** ******** no cough respirations even *** *********** GASTROINTESTINAL: ** ****** ** ******** and ****** *** ***** ********** • GENITOURINARY: ****** any ** ************ ************* alert *** ***** reminder ** *** *** month ****** ********* speech ******** o ********* ** headache or *********** **************** ****** **** ** ********* ***** *** *********** reports of **** **** ****** 4/10 ** a scale with 10 ***** most severe· ************ ** ******** ********* bruising ***** ** ***** LYMPHATICS: no ******** ******* ENDOCRINOLOGIC: ** heat or **** intolerance ****** ******** *** ********** ** sweatingObjective: ********** ******** ******* **** * ***** test ****** **** amphetamines ******* *** ********* had **** used ******** Other ***** **** ***** work imaging *** ************ ****** *** ** **** to **** ******** *** **** use *** ******* ** **** a correct diagnosisAssessment: ****** ****** Examination: ** is a *********** ********* **** who ******* *** stated *** Client ** *********** ****** assessment *** noted ** ** *********** ** is ******* ************* *** *** ******* ***** ******** *** *** disheveled *** ****** ** ********* ** understand and answers ********* ********** ** ** ****** a difficult **** **** *********** *** ****** ** having ********** **** ******** ** ********* ***** as ** ******* ** ******* frequently having ** ** redirected to the ******** ******** *** ********** **** ** distraught as ** feels ** ** * burden ** ****** and ****** is ****** Client **** psychomotor ********* ********* ** inability ** sit ***** ******** up *** **** ** right *** ****** ********** ************ *** ******** starting and stopping in ************ of ************ ****** is incoherent ** ** ******* ****** **** ********** thought ******** thinking the ***** ** hungry so ** puts **** down drain ******** ***** ****** ** the reason his ******* ** ******* and unfocused ******* ******* ** ********* *** ***** Client **** ******* hallucinations hearing *** ***** **** ** *** ********* ****** any ******** ideations ****** ** ******** appetite ** **** ******* ** ******** *** client *** ****** ******* **** poor judgmentDiagnostic *********** There *** a variety ** differential ********* that *** ** suggested to *** ******* including substance-induced psychosis ***************** ********* ** ************* ** ************** *** delusions caused by *** direct ******* of a ********* ** withdrawal **** * ********* ** *** ******* ** ******** (Tamminga ***** Alcohol ************ ******** ******* hallucinogens opioids and ************* *** **** **** ** the ********** **** *** *********** ********* *** patient *** ** ********* with ***************** ********* ** his ** *** hallucinations *** ********* exceed ***** **** ********** ********* substance intoxication ** ********** ******* the **** that the ******* may **** ** *********** ** *********** ********* ***** ******* ** has * ******* ** *************** *** which can contribute ** ********* ******** ***************** ********* ******** *** ******** ** the ********* The ******** of ************ *** ******* ** his ***** ******** this ********* Common symptoms ** *********************** psychosis include ************** ********* and agitation Relevant ********* ******* amphetamine and cocaine-positiveurine ***** *** ******** methamphetamine *** ******* pertinent negative ********* ** history of ******* ********* disorders *** ****** ************ diagnosis is apsychotic ******** *** to ******* medical ********* **** ******** ** ************* ** hallucinations ** ********* that are ****** ** other medical ********** ********** ***** *** ***** ****** *** infections ** the ******* ******* ****** stroke ******** and ******** ********* ********* *** **** cause ********* *** diagnosis ** *** ******* ** the ******* *** * *************** ******** ******** ** medical illness **** ** ********* **** **** ***** ********* *** to **** ******* ** drug ********** ** delirium ****** ** medication ********** ********** ***** *** ***** ** *** a ******* ** **** ********* ********** and radiculopathy ***** *** to the ********* ** **** ********* Consequently ** ** *********** **** *** *********** ******** are attributable ** * ******* ********* ********* his ***** ** ******** ******** ** ************** ********* ******* ******* *************** *************** ** discourse *** ******* ********** relevant ** *** **** **** GC *** a ******* ** medical conditions ********* neuropathy ***** may ** ********** **** *** ******* nervous ****** ********** ***** *** ***** *** ******** ****** ** **** no ******** diagnostic ***** ** findings *** ********* ** relation to ******* ********** *** third ************ ********* ** the unspecified ******** of ************* *** ***** ********* ********* This **** ** **** when *** ********* ******* *** ** *********** *** ******** ****** that the presentation **** not **** *** ******** for *** ******** schizophrenia ******** *** psychotic ********* (Hensel ** ** 2019) It **** ****** ** situations ** which ***** ** ************ *********** ** **** * **** ******** diagnosis The ******** that *** ****** **** ********* include ********* ************** ************ ****** ******* ************ ** ********* behavior *** flattening ****** *** ***** symptoms *** ******* *** *********** *** *********** problems at **** *** ** **** ******* *** ********** ******** ******** *** ******* ********* (Hensel et ** ***** **** ******** *** ****** ******* GC's ******** include ************ ******** ************** ******** *** ***** ***** ** him) delusions (believing *** ***** ** ravenous) ********* *** ******** ****** These symptoms *** ********** ** a ****** ****** ******* *** *** ******* ********* ** unclear based ** the provided **** The ********* positive is *** presence of ****** psychiatric ******** ***** *** ********* ******** ** the ******* of ******** *********** ***** *** ********* and ***** ** symptoms (Hensel et ** ******************* **** case * ***** **** *** *********** ********** *** diagnosis ** *** ******* ******* **** ** *** ********** found **** *** diagnostic criteria for ***** TR **** ****** **** ** *** disorders like *********** ***** are in ****** ** and *** in *** ******* ***** * ******* * lot **** ********* ********* situations *** ****** up **** ******** diagnoses based ** ***** ******** *** *** ********* tests ** I *** *** ****** ** do another differential ********* I ***** *** **** *** blood ***** *** I ***** **** *** ******** ********* Imaging (MRI) ** **** ** *** ********* ***** to *** ** there was ******* ******** ******* like a central ******* ****** ******** ** ******** that ***** be causing *** ********* ******** ********* ** al ******* is **** essential to ******** ***** *** ******* issues **** ** ******* the ******* against their will ** ** *********** if ***** ********* ***** **** * ****** to ********** or ****** ************ *** patient should thoroughly ******** *** ******* ****** ******** ******* *** ********* ************ ** ******* to *** ***** *** benefits of *********** Previous ************* *** ********* ***** *** **** *********** ** GC's ******* ***** ** health Therefore ** ** ********* to ******* *** ****** network *** ********* sources ** tension in *** **** As **** ** ********* ****** *** ********** ******* ** should *** ******* to reduce **** *** educate ***** on *** mental *** physical ****** ***** ********** with substance *** ***** **** ******* ** substance ***** he ** she may **** ** ****** ** ******* and substance ***** ********* ******** Case *********** *** Treatment Plan:According ** the studies ******** ***** **** is required to **** *** *** medical disease ************ to *** ********* **** includes * ************* ********* panel (CMP) ******* ******** **** and vitamin **** ***** ******* & ******* ***************** psychosis ******** * referral to a ********** for * ******** *********** ********* *** ********* ** this ****** ********** his ******* symptoms *** medical *********** ** ******** ** ***** ** ******** ** should be ******** ** a **** abuse treatment program ** ******* *** *************** ********* and should be ********** ** ******** attending ********* abuse counseling and ******* *********************************** *************** ******* ********* *********** such ** ********** *** *********** *** ***** ** ************* **** include ******** or swellingof *** **** **** ***** legsand ****** ** vision clumsinessand difficulty with ******** *** ******** vision(Salvi ** ** 2019) *** recommended medication ** the *** ** ************** *********** This **** ******* *** **** ** ******* ******** ***** ********* ***** retention ******* ****** *** ************ ** * ****** ** ******** *** ********** receptor *** *** histamine H1 receptor ***************** ***** ********** psychotherapy is included in *** ******************* ************ ** ******* underlying ************* ****** enhance ****** strategies *** ****** ** ** ******** *** ******** ********** ************* may **** afew ***** *** ** ******* *** *********** ** painful ******** *** *********** ***** *** **** ****** **** *********** ****** at ***** *** pharmacological interventions are ********* ******* **** ***** ***************** conditions *** ******** **** ************* ************ ********* *** ************************ ***** ************ (PMHNP) ****** **** * conversation **** *** patient about *** ********* risks *** ******** ** *** prescribed *********** **** will enable the patient ** ** aware ** *** ******* ********* *** ******** report **** ** **** ***** Furthermore ***** ***** to ******************* the patient about *** ******* why **** should *** ******** **** ****** their medication ******* first ********** ***** ********** provider ** part ** patient ********* ** ** informed ***** *** ***** ********** **** ****** medication ***** with **************** ***** ****** ******** ******* and ******* ***** ** ** ********* ** ** aware **** combining over-the-counter ***** ******* *** medication *** *********** ****** ** **** ********* **** *** **** ** serious ****** ****** ********* ***** damage ****** ******* *** ***** ****** *** ***** ****** also promote ********** **** ********** *** ******* explanations on *** drugs and ******* *** ****** both mental *** ******** health ** **** as ***** patternsDisposition ** the ********* was ********** ** continue attending *** ********* case ********** *** ******* sessions ** part ** *** ********** ********* program ************ *** PMHNP **** ******* a **** assessment ** determine whether *** patient is ** **** *** ** *** mental health ****** *** then ******* * **** ** mitigate those ************** ************** ** **** emergency ***** ******* including *** *** the client's ****** **** *********** number) ******** him ** ** ** the nearest ********* **** ** **** *** ** ** ******* ******** suicidal ** ******************** ************* ensure ****** **** *** ** ** ** ********* ** ************ ****** *** hospital and therapist records ****** **** ******* *** treatment ******* **** **** ***** for * comprehensive ************* of *** condition *** ****** *** ******* ** ******** ****************** Understanding *** Agreement:PMHNP ****** **** **** GC ** ***** ** *** ******* of *** ********* plan **** ** drugs side effects *** the significance ** ******** ** *** ******* PMHNP ****** as **** ******* if ******* ******* ** ***** to *** ********* planFollow-up **** ******** ****** set ** * ********* ******* **** GC's ******* **** ********* ***** as ****** ** take **** ** his ****** ******** *** **** ** eye *** for *** possible **** ******* ** *** *************** ******* *** ************* **** ******* extensive blood tests ** rule *** *** possibility ** ******* conditions contributing to psychosis ****** *** also responsible *** informing ******** **** ******* ** ******** *** **************** ** ClinicGC ****** **** ******* ****** ****** *** ********** ** her ******** ********** efficacy *** ******* ******* ******* ******** can only be ******* *** *********** *** **** ** ************ ongoing *********************** * * (2020) ********* ******** of antipsychotic ******** ******* ******** *********** bindingNew England ******* of *************** *************** * * ******** * * ***** * ********** * **** * ******* * O ***** Bolton * * (2019) **** *** ********** ******* *** a future ************* ********* ***** an ***** diagnosis ** *********** psychotic ********* a **************** studyJournal ** Psychiatric *********** 105-112Herrmann * ****** * ****** * ***** * Stadler J Mylius J ***** **** * ****** ****************** ******** *** ******* system *** ********** magnetic resonance ******* ** ultra-high magnetic ********** ******** ************* * ******* G Aguglia * **** S ***** * Martinotti G & ******** C (2019) ********* use of ***************** ************** ** bipolar disorder: * ****** of ******* ******************** ** *********** Practice®25(4) 318-327Sarmiento C ***** *** * ****** ********** *** *********** ****** ** mental ********** ********** ***** ************ ** *********** *** Individual Differences: *********** ********* *** ********** *********** ************* * ***** ******* * * ****** ***** episode ********* ******* ******* evidence-informed *************** and introduction ** * ********** guided ************* *** ********** Psychiatric ************ ************* C ****** ***************************** ********* ********