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To Prepare

  • Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
  • Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
  • Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Consider patient diagnostics missing from the video: Provider Review outside of interview:
    Temp 98.2  Pulse  90 Respiration 18  B/P  138/88
    Laboratory Data Available: Urine drug and alcohol screen negative.  CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)

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: 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-TR 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. 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 determinates 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.).

Running head: WEEK 4 ASSIGNMENT 1

Week 4: Mood Disorders in Adults

Melvis Nde

NRNP-6665-15-PMHNP Across the Lifespan

Walden University

Instructor Name: Dr. Hopkins

March 26, 2022


Assessing, Diagnosing, and Treating Adults with Mood Disorders

People who suffer from mood disorders are suffering from mental conditions that affect

their psychological well-being primarily (Gross et al., 2019). People with mood disorders often

experience a significant impact on their lives, relationships, and work. However, by combining

psychotropic drugs with psychotherapy, these disorders can be effectively treated. A focused

SOAP note including subjective and objective data is the task of this week’s assignment for the

assigned case study.

Focused SOAP Note


CC: “I have taken medications and discontinued them in the past. I don’t believe I require them.”

HPI: The client is a Caucasian female in her late twenties who has been referred for a mental

health evaluation. She says she’s had depression, anxiousness, and bipolar illness in the past, but

she’s not on any medication right now. She says she was on an “L” medicine, which helped but

“squashed my creativity.” Prior to consulting with a mental health professional, the client had

been hospitalized four times. “I suppose I may have been hearing things,” she says of her first

hospitalization when she was a teenager and had been awake for four to five days with no sleep.

Her mother, she claims, had her admitted to a mental health facility. She attempted suicide in

2017 by taking too much Benadryl. She was recently hospitalized in spring 2020 when the police

took her to the ER because she was dancing in a field while playing guitar while wearing her

nightgown. “I have these instances when I don’t want to get out of bed four to five times a year,”

she says. I’m completely exhausted. I’m not in the mood to accomplish anything. I don’t have any

desire to be creative. This normally happens after four to five days of being awake. There is talk


about me being depressed, but I was not assured. It’s possible that I’m fatigued from working so

hard,” she says, adding that she feels inspired and driven during moments of inspiration. “I enjoy

those times,” she says. That’s why I don’t always remember to take my prescriptions. I have a lot

of energy and can do a lot of things. I can go 4-5 days without sleeping. My friends say I talk too

much and look disorganized.” She describes herself as toxic during her creative phases, which

last around a week.

Past Psychiatric History:

 Depressive disorders, bipolar disorders, and anxiety disorders have all been diagnosed.

 The most recent hospitalization occurred in the spring of 2020 with four hospitalizations


 There was a suicide attempt in 2017 with a Benadryl overdose.

Medication trials and current medications:

 The client states that: “Taking Zoloft made me feel like I was on a drug high. I couldn’t

sleep, I couldn’t think straight”.

 Weight gain was associated with Risperidone and Seroquel

 The client states that: “My reaction time seems to be slower after taking Klonopin”.

 “After I stopped taking a medication that began with “L” my creativity flourished but the

medication squashed my creativity”

Psychotherapy or previous psychiatric diagnosis: Bipolar disorder, Depression, Anxiety

Family Psychiatric/Substance Abuse”

 Schizophrenia-stricken father estranged since the age of 8-10.


 Her mother had a history of self-injury including cutting (self-injury) and bipolar


 Brother had no knowledge of his mental health issues; he did not seek treatment

Substance Current Use:

One pack of cigarettes is claimed to be smoked by the client every day. “It makes me paranoid,”

she says about cannabis. She denies drinking, saying, “alcohol and I don’t get along.” She claims

she has never used cocaine, stimulants, benzodiazepines, hallucinogenic drugs, opiates, or

inhalants. She drank when she aged 19 last time.

Allergies: There have been no reported allergies.


General: She dismisses any weight gain or reduction. Times of extreme sleeplessness, high

energy, and “creativity” are followed by periods of low energy, poor motivation, and

oversleeping, according to her.

HEENT: There was no report of dizziness, headaches, epistaxis, ear or eye pain, nasal discharge,

blurred vision, or changes in vision. No symptoms of difficulty swallowing were reported.

Skin: Rashes or abnormal bruising have not been reported.

Cardiovascular: The patient did not experience tightness, shortness of breath, or chest pain.

Respiratory: No complaints of breathlessness, cough, or nighttime dyspnea have been made.

Gastrointestinal: There has been no complaint of diarrhea, upset stomach, or constipation.

Genitourinary: No pain, urgency, or frequency of urination have been reported by the patient.


Neurological: Patient-reported no ataxia, headaches, or numbness.

Musculoskeletal: There are no complaints of joint or muscle pain

Hematologic: It has not been reported that there has been any bleeding or bruising

Lymphatics: Neither swollen nor painful lymph nodes reported

Endocrinology: Hypothyroidism is reported by the patient.

2. Objective

Review of Systems:

GENERAL: An appropriate mood, attitude, and general appearance are present. Affect and

mood are congruent with each other.

HEENT: There are no traumas or deformities noted on the head.

SKIN: Warm and dry skin appears to be free of rashes, wounds, or ulcers.

CARDIOVASCULAR: Normal heart sounds with a normal rhythm.

RESPIRATORY: The breathing is easy, non-labored, without wheezing or shortness of breath.

NEUROLOGICAL: There are four things the client is good at alertness, orientation,

pleasantness, and cooperation.

MUSCULOSKELETAL: There is no difficulty moving any of the extremities.

Diagnostic results:


As of right now, no results have been obtained from diagnostic testing. Certain drugs can have a

harmful influence on the kidneys, liver, and heart, thus baseline blood levels should be

established before commencing treatment (Akkerman-Nijland et al., 2021). It may be necessary

to obtain a second EKG in the future to compare.


Mental Status Examination (MSE):

The client is 25 years old, her appearance is that of a young Caucasian female who looks

her age. She is perceptive, organized, and polite. She is organized and well-dressed. Except

for a few instances of forced speech, the tone and effect of the speaker are consistent and

appropriate. She fantasized about being famous by selling her artwork to movie stars,

applying make-up, and writing and publishing her memoirs, all of which she believed would

make her famous. When assessing a client, the practitioner observes objectively and

evaluates their mood, effects, ability to concentrate and reason, and insight, which enables

the practitioner to gain a clear understanding of their behavior and cognitive capabilities

(Pijnenborg et al., 2019). There are brief episodes of “creativity” for a week or two at a time

when the client feels worried. It’s hard for the client to focus, he has a lot of energy, he

chatters excessively, he wants sexual relations with strangers, and he only sleeps three hours

a night during this period.

It is reported that the client has been in bed for more than a week following her

“creativity” week, that she lacks energy and motivation, that she is losing interest in her


favorite activities, and that she feels useless. Currently, she is not experiencing any problems

with vision, hearing, or sensation; Her past experiences have, however, led her to hear voices

telling her she is smart and wonderful. This does not appear to affect her short-term or long-

term memory. In spite of her “creativity,” she seems to lack judgment and impulse control, as

she was caught by the police playing with her guitar in her nightgown, and she finds it

acceptable to use her guitar in public. Despite experiencing depressive episodes, she appears

to have no suicidal thoughts or plans. She is occasionally absent from her Aunt’s bookshop

due to her depressive periods. While planning to attend a cosmetology school, the consumer

enjoys drawing and writing.

Diagnostic Impression:

1. Bipolar Disorder Moderate (F31.2): A manic episode followed by a severe depressive

episode led to the selection of her for the study. She exhibits symptoms of manic

behavior, such as an extravagance, inflated self-esteem, a decreased sleep schedule, being

talkative more often than normal, having a flurry of ideas and racing thoughts, and

engaging in additional activities that can cause her harm. The symptoms she exhibited are

all those described in the DSM-5 (APA, 2013). A significant depressive episode is

frequently followed by bipolar I disorder.

2. Generalized Anxiety Disorder: In order to cope with uncomfortable feelings, the client

could engage in impulsive behavior due to ruminating fears that might be mistaken for

racing thoughts (APA, 2013). Therefore, because it lacks the manic behavior linked with

bipolar illness, this diagnosis is ruled out. Therefore, this diagnosis could explain the

patient’s symptoms of restlessness, trouble concentrating, and fatigue


3. Borderline Personality Disorder: Both bipolar disorder and Borderline personality

disorder exhibit emotional instability and impulsive behavior (APA, 2013). At the time,

the client’s subjective and objective symptoms appear to be at variance with the DSM-5

criteria, since she does not meet the majority of the five criteria for this diagnosis. (APA,


Case Formulation and Treatment Plan

Relying on the clinical symptoms that matched the DSM-5 criteria for a diagnosis for this

disease, the client was confirmed with Bipolar Personality Disorder. Due to her promiscuous

behavior, she has exaggerated self-esteem, decreased sleep demands, poor judgment, and a lack

of self-control. She is friendlier than usual, has a flight of opinions and racing emotions, utterly

irrational mental processes with extravagant beliefs, and delusional thinking. Having followed

these bursts of “creativity,” the client has tiredness, trouble getting up in the morning, a

decreased interest in enjoyable activities, a lack of desire, and feelings of hopelessness.

To prevent adverse effects, the client will be started on 25 mg of Lamotrigine BID and

titrated till the desired effect is achieved (Kim et al., 2020). The client will also be advised to

seek psychotherapy. Because the client was concerned about weight gain from her previous

prescription prescriptions, Lamotrigine was chosen because weight gain is uncommon with this

medication, and it has been authorized by the FDA for the treatment of Bipolar disease (Wang &

Osser, 2020). The client has expressed worry about weight gain, which is a common side effect

of various mood stabilizers and atypical antipsychotic drugs. To promote treatment compliance,

the client will be told that resolving her complaints might take a few weeks, as well as the


common side effects of rash, vertigo, and nausea (Rosenberg et al., 2021). Because of the risk of

dizziness as a side effect, the client avoids driving if dizziness occurs.

She is also instructed to take the prescription precisely as prescribed and not to stop

taking it without consulting her doctor first. She is also aware that taking this medicine may

result in birth deformities and reduce the efficacy of birth control, so she should discuss these

concerns with the client before beginning the prescription. While using the drug, it is

recommended that the client use an additional form of birth control. Because the medicine may

have an effect on the kidneys, liver, or heart, the client should have baseline testing done before

beginning to take it (Akkerman-Nijland et al., 2021). She is also educated that psychotherapy is

essential due to the fact that studies have proven that psychosocial treatments which include

CBT, IPSRT, and family-focused therapy improve restoration quotes and decrease symptom

recurrence in these people (Camardese et al., 2018). If a client attempts suicide, a suicide hotline

number should be supplied, and the client should be urged to contact the hotline or go to the

nearest emergency center for treatment and evaluation. The client will be requested to return in

one week to treat any side effects and monitor the progression of her disease.


I feel the practitioner performed admirably in examining the client and addressing her

medical history and medications. I’ve learned that reviewing prior medicines with the client is

crucial in choosing the correct psychiatric prescription to provide based on the client’s prior

experiences and bad effects of previously prescribed meds. As part of the ethical and legal issues

for this case study, the client will feel more at ease expressing her symptoms and behaviors with

the practitioner. The practitioner should ensure that the client is well-educated about her

treatment choices so that she may make an informed treatment decision.


The client should also be educated and informed on the dangers and advantages of

psychotropic medication, such as side effects and symptom relief. According to non-maleficent

ethical standards, the practitioner must assess the client’s safety in relation to her actions, taking

into account any suicidal inclinations or plans. The practitioner may risk legal implications if this

ethical norm is not fulfilled. The ethical concept of autonomy must be honored since the client

has the right to pick their own treatment plan after being fully educated and provided with all

treatment options. Because she claims to have had sex with multiple persons during her manic

episodes, the client should be educated on safe sex techniques in order to avoid STDs for health

promotion and disease prevention purposes. To avoid unintended pregnancy, she should be

trained and informed on how to use birth control as directed, as well as how tablets can

occasionally create issues.



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