Assignment Prompt & Instructions
see attached
– ## Unit6assignment.docx
– ## PMHNP_Clinical_SOAP_Note_Template_2402C.docx
**## Unit6assignment.docx**
Unit 6 Case Study: An elderly client presents with complaints of manic symptoms. Read the scenario below and then follow the assignment directions on Tab 2.
Case Study Scenario:
At first, her husband noticed some restlessness; Mrs. Darcy had a hard time relaxing. It then progressed to an inability to fall asleep and stay asleep. For the past 6 weeks, she has been averaging 3–4 hours of sleep per night, compared to her usual 8–9 hours. In the past month, she has also taken on some new projects within the home. She decided to renovate their kitchen and their master bathroom and redo their backyard deck all within the same week. She has contacted numerous contractors and purchased various home improvement magazines and books but has not been able to progress further into the planning stages, as she becomes easily distracted by other things. When her husband asks her to slow down and perhaps focus on one project, she becomes irritated and yells that he never lets her do anything that she wants. He feels that she has been much more short-tempered in the past month.
In the past week or so, she has spent most of the day in church, praying. Although Mrs. Darcy is a Christian, she usually attends church only once or twice a month. She indicated to her husband that she has been going more often in the past week because she needs to repent of her past sins. She has a “feeling” that if she does not repent her sins, something horrible will befall her family.
On mental status examination, Mrs. Darcy appeared well groomed but dressed in a youthful, “trendy” style. She was annoyed at coming to the hospital, as she felt nothing was wrong with her. Her thought process was tangential, but she could be redirected with some effort. Initially, Mrs. Darcy scoffed at the question of suicide, but she later made the comment that if she had to stay in the hospital any longer, hospital staff might as well “kill me now” as she cannot stand to be in a “prison.” Throughout the assessment, she paced back and forth in the interview room.
Her medications, which her husband brought in a dosette, include ramipril 5 mg qam, atorvastatin 40 mg q supper, escitalopram 15 mg qhs, lorazepam 2 mg qhs, pantoprazole 40 mg ac meals, and levothyroxine 75 mcg qam.
Her vital signs on initial presentation showed a blood pressure of 132/76 mm Hg, a heart rate of 103 BPM, and O2 saturation at 98%. The emergency physician ordered basic laboratory investigations, including complete blood count (CBC), electrolytes, creatinine, estimated glomerular filtration rate (eGFR), total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, and thyroid-stimulating hormone, which were all within normal limits.
The emergency physician determines that Mrs. Darcy may be at imminent risk and asks whether she should be on a psychiatric commitment order based on Mrs. Darcy’s comments about killing herself if she needed to remain in the hospital. She has been referred to you, the emergency psychiatric consultant, for further assessment and management of her suicide risk, mood, and behavior.
**Assignment Instruction**
Use the SOAP note template to complete the documentation with the information provided.
· Formulate appropriate diagnoses and design a treatment plan.
· Explain what further information you will explore to aid in accurate diagnosis.
· What other investigation will you consider narrowing down the diagnosis?
· Outline your evidence-based treatment plan.
**## PMHNP_Clinical_SOAP_Note_Template_2402C.docx**
Patient Name: XXX
MRN: XXX
**Date of Service: 01-27-2020**
**Start Time:** 10:00
**End Time:** 10:54
**Billing Code(s):** 90213, 90836
_(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)_
**Accompanied by:** Brother
**HPI:** 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
**S-** Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
**O-**
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits
Results of any Psychiatric Clinical Tests: BAI=34
MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.
**A -** with (ICD-10 code)
**Differential Diagnoses:**
**1. choose 3 differential diagnoses**
**2.**
**3.**
**Definitive Diagnosis:**
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1
**P-** Continue Fluoxetine increasing dose to 20mg.
Continue outpatient counseling: partial inpatient program continued with individual and group sessions
Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time
**## PMHNP_Clinical_SOAP_Note_Template_2402C.docx**
Patient Name: XXX
MRN: XXX
**Date of Service: 01-27-2020**
**Start Time:** 10:00
**End Time:** 10:54
**Billing Code(s):** 90213, 90836
_(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)_
**Accompanied by:** Brother
**HPI:** 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
**S-** Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
**O-**
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits
Results of any Psychiatric Clinical Tests: BAI=34
MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.
**A -** with (ICD-10 code)
**Differential Diagnoses:**
**1. choose 3 differential diagnoses**
**2.**
**3.**
**Definitive Diagnosis:**
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1
**P-** Continue Fluoxetine increasing dose to 20mg.
Continue outpatient counseling: partial inpatient program continued with individual and group sessions
Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time
**## Unit6assignment.docx**
Unit 6 Case Study: An elderly client presents with complaints of manic symptoms. Read the scenario below and then follow the assignment directions on Tab 2.
Case Study Scenario:
At first, her husband noticed some restlessness; Mrs. Darcy had a hard time relaxing. It then progressed to an inability to fall asleep and stay asleep. For the past 6 weeks, she has been averaging 3–4 hours of sleep per night, compared to her usual 8–9 hours. In the past month, she has also taken on some new projects within the home. She decided to renovate their kitchen and their master bathroom and redo their backyard deck all within the same week. She has contacted numerous contractors and purchased various home improvement magazines and books but has not been able to progress further into the planning stages, as she becomes easily distracted by other things. When her husband asks her to slow down and perhaps focus on one project, she becomes irritated and yells that he never lets her do anything that she wants. He feels that she has been much more short-tempered in the past month.
In the past week or so, she has spent most of the day in church, praying. Although Mrs. Darcy is a Christian, she usually attends church only once or twice a month. She indicated to her husband that she has been going more often in the past week because she needs to repent of her past sins. She has a “feeling” that if she does not repent her sins, something horrible will befall her family.
On mental status examination, Mrs. Darcy appeared well groomed but dressed in a youthful, “trendy” style. She was annoyed at coming to the hospital, as she felt nothing was wrong with her. Her thought process was tangential, but she could be redirected with some effort. Initially, Mrs. Darcy scoffed at the question of suicide, but she later made the comment that if she had to stay in the hospital any longer, hospital staff might as well “kill me now” as she cannot stand to be in a “prison.” Throughout the assessment, she paced back and forth in the interview room.
Her medications, which her husband brought in a dosette, include ramipril 5 mg qam, atorvastatin 40 mg q supper, escitalopram 15 mg qhs, lorazepam 2 mg qhs, pantoprazole 40 mg ac meals, and levothyroxine 75 mcg qam.
Her vital signs on initial presentation showed a blood pressure of 132/76 mm Hg, a heart rate of 103 BPM, and O2 saturation at 98%. The emergency physician ordered basic laboratory investigations, including complete blood count (CBC), electrolytes, creatinine, estimated glomerular filtration rate (eGFR), total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, and thyroid-stimulating hormone, which were all within normal limits.
The emergency physician determines that Mrs. Darcy may be at imminent risk and asks whether she should be on a psychiatric commitment order based on Mrs. Darcy’s comments about killing herself if she needed to remain in the hospital. She has been referred to you, the emergency psychiatric consultant, for further assessment and management of her suicide risk, mood, and behavior.
**Assignment Instruction**
Use the SOAP note template to complete the documentation with the information provided.
· Formulate appropriate diagnoses and design a treatment plan.
· Explain what further information you will explore to aid in accurate diagnosis.
· What other investigation will you consider narrowing down the diagnosis?
· Outline your evidence-based treatment plan.
**## PMHNP_Clinical_SOAP_Note_Template_2402C.docx**
Patient Name: XXX
MRN: XXX
**Date of Service: 01-27-2020**
**Start Time:** 10:00
**End Time:** 10:54
**Billing Code(s):** 90213, 90836
_(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)_
**Accompanied by:** Brother
**HPI:** 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
**S-** Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
**O-**
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits
Results of any Psychiatric Clinical Tests: BAI=34
MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.
**A -** with (ICD-10 code)
**Differential Diagnoses:**
**1. choose 3 differential diagnoses**
**2.**
**3.**
**Definitive Diagnosis:**
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1
**P-** Continue Fluoxetine increasing dose to 20mg.
Continue outpatient counseling: partial inpatient program continued with individual and group sessions
Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time
**## Unit6assignment.docx**
Unit 6 Case Study: An elderly client presents with complaints of manic symptoms. Read the scenario below and then follow the assignment directions on Tab 2.
Case Study Scenario:
At first, her husband noticed some restlessness; Mrs. Darcy had a hard time relaxing. It then progressed to an inability to fall asleep and stay asleep. For the past 6 weeks, she has been averaging 3–4 hours of sleep per night, compared to her usual 8–9 hours. In the past month, she has also taken on some new projects within the home. She decided to renovate their kitchen and their master bathroom and redo their backyard deck all within the same week. She has contacted numerous contractors and purchased various home improvement magazines and books but has not been able to progress further into the planning stages, as she becomes easily distracted by other things. When her husband asks her to slow down and perhaps focus on one project, she becomes irritated and yells that he never lets her do anything that she wants. He feels that she has been much more short-tempered in the past month.
In the past week or so, she has spent most of the day in church, praying. Although Mrs. Darcy is a Christian, she usually attends church only once or twice a month. She indicated to her husband that she has been going more often in the past week because she needs to repent of her past sins. She has a “feeling” that if she does not repent her sins, something horrible will befall her family.
On mental status examination, Mrs. Darcy appeared well groomed but dressed in a youthful, “trendy” style. She was annoyed at coming to the hospital, as she felt nothing was wrong with her. Her thought process was tangential, but she could be redirected with some effort. Initially, Mrs. Darcy scoffed at the question of suicide, but she later made the comment that if she had to stay in the hospital any longer, hospital staff might as well “kill me now” as she cannot stand to be in a “prison.” Throughout the assessment, she paced back and forth in the interview room.
Her medications, which her husband brought in a dosette, include ramipril 5 mg qam, atorvastatin 40 mg q supper, escitalopram 15 mg qhs, lorazepam 2 mg qhs, pantoprazole 40 mg ac meals, and levothyroxine 75 mcg qam.
Her vital signs on initial presentation showed a blood pressure of 132/76 mm Hg, a heart rate of 103 BPM, and O2 saturation at 98%. The emergency physician ordered basic laboratory investigations, including complete blood count (CBC), electrolytes, creatinine, estimated glomerular filtration rate (eGFR), total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, and thyroid-stimulating hormone, which were all within normal limits.
The emergency physician determines that Mrs. Darcy may be at imminent risk and asks whether she should be on a psychiatric commitment order based on Mrs. Darcy’s comments about killing herself if she needed to remain in the hospital. She has been referred to you, the emergency psychiatric consultant, for further assessment and management of her suicide risk, mood, and behavior.
**Assignment Instruction**
Use the SOAP note template to complete the documentation with the information provided.
· Formulate appropriate diagnoses and design a treatment plan.
· Explain what further information you will explore to aid in accurate diagnosis.
· What other investigation will you consider narrowing down the diagnosis?
· Outline your evidence-based treatment plan.
**## PMHNP_Clinical_SOAP_Note_Template_2402C.docx**
Patient Name: XXX
MRN: XXX
**Date of Service: 01-27-2020**
**Start Time:** 10:00
**End Time:** 10:54
**Billing Code(s):** 90213, 90836
_(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)_
**Accompanied by:** Brother
**HPI:** 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions
**S-** Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.
Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.
Reviewed Allergies: NKA
Current Medications: Fluoxetine 10mg daily
ROS: no complaints
**O-**
Vitals: T 98.4, P 82, R 16, BP 122/78
PE: (not always required and performed, especially in psychotherapy only visits)
Heart- RRR, no murmurs, no gallops
Lungs- CTA bilaterally
Skin- no lesions or rashes
Labs: CBC, lytes, and TSH all within normal limits
Results of any Psychiatric Clinical Tests: BAI=34
MSE:
Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.
**A -** with (ICD-10 code)
**Differential Diagnoses:**
**1. choose 3 differential diagnoses**
**2.**
**3.**
**Definitive Diagnosis:**
Major Depressive Disorder, recurrent, without psychotic features F33.4
Generalized Anxiety Disorder F41.1
**P-** Continue Fluoxetine increasing dose to 20mg.
Continue outpatient counseling: partial inpatient program continued with individual and group sessions
Non-pharmacological Tx: Psychotherapy Modality used: CBT
Pharmacological Tx: (be specific and give detailed Rx information)
Education: discussed smoking cessation
Reviewed medication side effects and adherence importance
Follow-up: in one week or earlier if any depressive symptoms worsen.
Referrals: none at this time
– 1
– 2