Focused SOAP Note and Patient Case Presentation
Consider the experiences you have had thus far, either in the healthcare workplace or at your practicum site. As you likely know, a nurse’s 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’s status. A central skill of advanced practice nursing, then, is the ability to present a patient’s history, symptoms, diagnosis, and treatment plan to relevant parties involved in treatment.
Develop a focused SOAP note on one of the patients you have examined in your clinical practicum. (40 years old female with Anxiety Disorder)
• Assess patients across the lifespan in mental health settings
• Formulate differential diagnoses for patients across the lifespan in mental health settings
• Develop plans of care for patients across the lifespan in mental health settings
• Advocate health promotion and patient education strategies across the lifespan
• Develop a case study presentation based on a clinical patient
Discuss Subjective data:
• Chief complaint
• History of present illness (HPI)
• Psychotherapy or previous
• Pertinent histories and/or ROS
Accurately 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.
Discuss Objective data:
• 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
Accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.
Discuss results of Assessment:
• Results of the mental status examination
• 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’s symptoms
Accurately documents the results of the mental status exam.
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.
Discuss treatment Plan:
• 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.
Clearly 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.
Reflect on this case. Discuss what you learned and what you might do differently.
Reflections are thorough, thoughtful, and demonstrate critical thinking.
Focused SOAP Note documentation
The response clearly, accurately, and thoroughly follows the Focused SOAP Note format to document the selected patient case.
Presentation style is exceptionally clear, professional, and focused.
Template to follow
Focused SOAP Psychiatric Evaluation Template
CC (chief complaint):
Substance Current Use:
• Current Medications:
• Reproductive Hx:
Mental Status Examination:
Case Formulation and Treatment Plan:
CC (chief complaint): “ I am always anxious”
The 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). 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).
Substance Current Use:
The 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.
The 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).
• Current Medication:
Dry air makes the patients skin flair more
• Reproductive Hx:
The patient is married and has no history of sexual health issues. The patient is also a mother of two children who are grown up.
• GENERAL: Show signs of acute distress
• HEENT: The head is filled with white patches and red pimples, eyes, nose, and throat.
• SKIN: the skin is red, pale, has cracks, and discoloration of the nails.
• CARDIOVASCULAR: no palpitation
• RESPIRATORY: no wheezing or shortness of breath
• GASTROINTESTINAL: No heartburn, diarrhea, or nausea.
• GENITOURINARY: No urinary urgency or frequency
• NEUROLOGICAL: the patient is not oriented
• MUSCULOSKELETAL: no muscle pain
• HEMATOLOGIC: the blood is in good condition no signs of infections or hematologic disease
• LYMPHATICS: good
• ENDOCRINOLOGIC: good
Anxiety disorder is caused by stress resulting from uncomfortability caused by psoriasis disease.
Mental Status Examination: Motor: No psycho-motor retardation or any agitation
Mood; no disturbances
Behavior: the patients are restless, do not maintain appropriate eye contact, although cooperative.
Appearance: The patient appears older than forty years, thin, and not so hygienic.
Speech: The patient has a normal tone, fluent while speaking, and sound volume.
Cognition: The patient has a good memory, does not fully pay attention, but fund of knowledge,
judgment, and impulse control: Good
Constant 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.
I 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).
Case Formulation and Treatment Plan:
I 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.
Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93.
Fleming, 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.
Lamb, 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‐sectional study in a tertiary referral setting. British Journal of Dermatology, 176(4), 1028-1034.
Stein, M. B., & Sareen, J. (2015). Generalized anxiety disorder. New England Journal of Medicine, 373(21), 2059-2068.