Posted: March 31st, 2024

SOAP Note: Adults With Mood Disorders

Assignment: Assessing, Diagnosing, and Treating Adults With Mood Disorders

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It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. 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.
Survey the Focused SOAP Note format, which you will use to finish this Assignment. There is additionally a Focused SOAP Note Exemplar gave as a manual for Assignment assumptions.

Survey the video, Case Study: Petunia Park. You will utilize this case as the premise of this Assignment. In this video, a Walden employee is surveying a false tolerant. The patient will be addressed onscreen as a symbol.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.

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: Ace my homework – Write my paper – Online assignment help tutors – 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 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. Get custom essay samples and course-specific study resources via course hero homework for you service – Include pertinent positives and pertinent negatives for the specific patient case.
Plan: What is your arrangement for psychotherapy? What is your arrangement for treatment and the board, including elective treatments? Incorporate pharmacologic and nonpharmacologic medicines, elective treatments, and follow-up boundaries just as a reasoning for this treatment and the executives plan. Likewise join one wellbeing advancement movement and one patient schooling technique.
Reflection notes: What would you do differently with this client if you could conduct the session again? Ace my homework – Write my paper – Online assignment help tutors – Discuss what your next intervention would be if you were able to follow up with this patient. 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 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.

Focused SOAP Note

Student’s Name
Institutional Affiliation
Course
Instructor’s Name
Date

Patient Initials: ___Jamison____ Age: ___24____ Gender: ___F____ Ethnic group:
Latin American
Subjective:
CC. (chief complaint): “I have a fit of uncontrolled anger that sometimes goes out of hand. My rage started growing inside me for the last two years, and little things usually get me angry, especially when people speak offensively to me. Another challenge that I am experiencing is my uncontrolled sleeping behavior, going for days without proper sleep. Another challenge is that I have developed low self-esteem, which has made me start isolating myself from other people. I am also experiencing continuous emotional changes, being happy, and then suddenly switches to sadness. Another challenge concerns a terrible judgment of other people; even to fight with these people, I have an awful judgment towards them.
I have been experiencing mood disorder for four years now, and the symptoms are continuing to be profound over time. During the first two years, the signs were not so severe, and the primary symptom I had was emotional crashes. During the third year, I started to experience racing thoughts that were accompanied by continuous overthinking. The mood disorders were so intense whenever I was going through challenging life moments. During the fourth year, I started to experience sleeping disorders, going for days without sleeping, and sometimes the I could sleep continuously for long hours.
The mood disorder symptoms have affected my social life negatively. I isolated myself from other people because other people could notice the challenges I faced. Another challenge is that the mood disorder symptoms affected my productivity in daily activities. The primary sign that affected my performance was sleeplessness which made me feel exhausted. The lousy judgment symptom made me result in conflicting moments with the people around me. The terrible judgment made me develop a negative implication and perception towards other people. The mood disorder lowered my self-esteem, and low self-esteem affected my communication skills.”
HPI: Jamison is a 24-year-old Latin American female who comes to an assessment program complaining about mood disorder challenges. The mood disorder has severely affected the social life of Jamison especially her anger. Jamison feels odd concerning the mood disorder, and she dramatically needs medical intervention.
Past Psychiatric History:
· General Statement: Diagnosed with Bipolar disorder last year in July.
· Caregivers (if applicable): Lives with her single mother and two brothers
· Hospitalizations: Jamison was hospitalized once at the age of 17 years.
· Medication trials: Non-multivitamin.
· Psychotherapy or Previous Psychiatric Diagnosis: No previous psychotherapy diagnosis.
. Diagnosis: Mood disorder.
Substance Current Use and History: Jamison has never used any substance in her life.
Family Psychiatric/Substance Use History: No family member with a history of using substances.
Psychosocial History: Jamison works as assistance in social organization. She used to interact with her friends very well without any conflicts.
Medical History:
· Current Medications: Jamison has no current medication
· Allergies: Jamison has no known allergies

ROS:
GENERAL: Stable body weight.
HEENT: absence of nasal congestion.
SKIN: Jamison has no skin rashes, any sores, or rashes.
RESPIRATORY: Normal breathing with no difficulties
CARDIOVASCULAR: Stable chest without ant infection or pain.
MUSCULOSKELETAL: Stable back with no pains or any other muscle pain.
NEUROLOGICAL: Stable mental condition without any signs of a headache.
PSYCHIATRIC: shows signs of anger and depression.
ENDOCRINOLOGIC: Experiences abnormal sweating.
REPRODUCTIVE: Not sexually active and unmarried.
ALLERGIES: No known allergies.

Objective:
One observation that I made from the patient during the assessment process is that the mood disorder severely affected the patient. Another observation from the patient is that the mood disorder developed slowly for four years since the patient had the first symptom. Another observation is that the mood disorder developed as a result of the psychological factor. The patient mentioned that four years ago, the patient did the final high school exam, and the patient didn’t pass the exam. Therefore, the likeliness of mood disorder developing as a result of exam failure is high. The external environmental factors also made the patient develop a mood disorder. All the friends the patient had passed their high school examination, and the patient felt terrible about the failure. Therefore, the mood disorder in the patient developed due to both psychological and environmental factors.
Another observation from the patient is that the patient was in a despair stage in how the patient dressed. The patient did not talk about suicidal thoughts, but I could see that the patient gave up on how the patient talked. Another observation that I made from the patient is that the mood disorder was developing to a long-term emotional state. Medical early medical intervention was essential to the patient. Another observation that I made was that the patient was remarkably in need of medical help since some symptoms such as headaches due to overthinking were developing.
Assessment:
From the examination results, the mental status of the patient was developing depression and bipolar disorders. Bipolar disorder is a mental condition characterized by extreme mood changes and varying emotions (Sadock, Sadock & Ruiz, 2015 – Research Paper Writing Help Service). The differential diagnoses that I applied to the patients were mental health evaluation, physical examinations, and medical history evaluation. The main aim of mental health evaluation was to determine the mental condition that made the patient have mood disorders. Physical examination on the patient was to determine the mood stability of the patient. The medical history evaluation was to develop information concerning past illnesses, surgeries, or allergies disorders that might have affected the patient when using medical intervention.
DSM–5 diagnostic criteria is a manual that medical practitioners use to assess and diagnose a mental disorder (Pai, Suris & North, 2017). DSM-5 diagnostic criteria rule out the first step in diagnosing a mental illness is determining the disorder’s cause. Through mental health evaluation diagnosis, I was able to determine the cause of the mood disorder. DSM-5 also rules out that it is crucial to decide on how the condition affects an individual. By physically examining the patient, I determined how the mood disorder affected the patient (Pai, Suris & North, 2017). DSM-5 also rules out that it is essential to decide on the best medical intervention to treat a mental disorder. I was able to develop the best medical solution by evaluating the medical health history. The primary diagnosis that I selected was mental health evaluation. The critical thinking process that made me choose mental health evaluation was t to understand the mood disorder from a more mental perspective. The pertinent positives with using mental health evaluation are that a medical practitioner gains more information concerning the patient. The relevant negative with mental health evaluation is time-consuming, and it’s hard even to understand the patient.
Plan:
My plan for psychotherapy is to create an intervention program for the patient to overcome the mood disorder. The intervention program will have a treatment process that will help the patient overcome the mood disorder. The pharmacological approach to the patient’s treatment will be through using medication that will alter the mental condition. The nonpharmacological treatment approach will entail the social perspective intervention. Alternative therapy to a mood disorder patient engages in social activities that will divert the mood disorder symptoms (Raymond, 2020). A health promotion activity to a mood disorder patient encourages the patient to engage in sporting activities to raise the brain’s serotonin levels.
Reflective Notes:
If the same client comes again for an assessment program, the first thing is to ask the patient whether the previous assessment was practical. In the second assessment, I will give the patient a chance to engage in more talk as I talk less in our conversation. The subsequent intervention after the second assessment will entail a long-term intervention that will change the patient’s point of view towards life. One legal consideration during an evaluation with a patient is ensuring that the information a patient provides remains confidential. A risk factor consideration that I must take before assessing a patient is signing a non-suicidal intervention. Signing a non-suicidal intervention program is essential since a mental disorder patient committing suicide is high.

References
Pai, A., Suris, A. M., & North, C. S. (2017). Posttraumatic stress disorder in the DSM-5: Controversy, change, and conceptual considerations. Behavioral Sciences, 7(1), 7.
Raymond Zakhari, D. N. P. (2020). The Psychiatric-Mental Health Nurse Practitioner Certification Review Manual. Springer Publishing Company.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015 – Research Paper Writing Help Service). Synopsis of psychiatry: behavioral sciences, clinical psychiatry. Wolters Kluwer.

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