Develop A Focused SOAP Note, Including Your Different 589342

Develop a Focused SOAP Note, including your differential diagnosis and

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: 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 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.).

Paper For Above instruction

The case of Petunia Park presents a complex clinical picture characterized by mood instability, impulsivity, substance use history, and episodes of high energy with decreased need for sleep. Developing an accurate diagnosis requires careful analysis of her clinical presentation, history, and diagnostic criteria outlined in the DSM-5-TR. This paper formulates a focused SOAP (Subjective, Objective, Assessment, Plan) note, providing a differential diagnosis, the rationale for the primary diagnosis, and a comprehensive treatment plan, including considerations for psychotherapy, pharmacology, and health promotion. Additionally, it reflects on the lessons learned and integrates ethical, social, and cultural factors influencing her care.

Subjective Data and Mental Status Examination

Petunia reports fluctuating mood states, with episodes of elevated energy, decreased sleep, increased productivity, and periods of profound depression. She describes feeling “squashed” by medication, but also recognizes the benefits of achieving a balanced state. She denies current suicidal or homicidal ideation, but her past history includes multiple hospitalizations, overdose, and hospitalization for suicidal gestures. Her substance use history includes nicotine and prior experimentation with marijuana, with no recent substance use. She is actively engaged in creative pursuits such as writing, painting, and music, which seem intertwined with her mood episodes. Her sleep varies significantly, from as little as three hours to over sixteen hours, depending on her mood state. She reports episodic intense feelings of euphoria lasting about a week, during which she feels highly energetic and less need for sleep, suggestive of mood cycling. Her physical exam and laboratory data are normal, with slightly elevated TSH, indicating subclinical hypothyroidism.

Differential Diagnoses

1. Bipolar I Disorder
2. Supported by her history of episodic mood elevation lasting about a week, decreased need for sleep, increased goal-directed activity, and heightened energy, which are hallmark features of manic episodes (American Psychiatric Association, 2013). Her episodes of depression between mood swings, combined with periods of high energy, are characteristic of bipolar I. The DSM-5-TR criteria require at least one manic or mixed episode, which she exhibits, making this the top differential.
3. Major Depressive Disorder with Mixed Features
4. While her predominant presentation involves depressive episodes, her episodes of increased energy and activity could suggest a mixed features episode (APA, 2013). However, the duration and severity of her manic episodes favor bipolar I over this diagnosis, as mixed features are usually observed within depressive episodes but less frequently as standalone episodes.
5. Borderline Personality Disorder (BPD)
6. Her impulsivity, unstable relationships (living with her boyfriend, conflicts with her mother), and mood swings could suggest BPD (Lieb et al., 2010). Yet, her episodic mood states are more episodic and intense than the chronic emotional instability typical of BPD, making it a less likely primary diagnosis.

Critical Thinking and Diagnostic Criteria

In diagnosing bipolar I disorder, the DSM-5-TR criteria specify a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week, accompanied by identifiable symptoms such as inflated self-esteem, decreased need for sleep, talkativeness, racing thoughts, distractibility, increased goal-directed activity or psychomotor agitation, and engagement in risky behaviors (APA, 2013). Petunia's episodes of high energy, decreased sleep, and engaging in multiple activities fit these criteria, especially considering the duration and intensity. Her depressive episodes, lasting weeks, further support this diagnosis.

In contrast, BPD's mood instability is chronic and reactive, with rapid shifts lasting hours to days, often triggered by interpersonal stressors (Lieb et al., 2010). Petunia’s mood episodes are more episodic and distinct, aligning more closely with bipolar disorder.

Management and Treatment Plan

Pharmacological Interventions

Based on her presentation, initiating mood stabilizers such as lithium or valproate would be appropriate, given their efficacy in preventing manic episodes (Yatham et al., 2018). Considering her history of medication side effects, particularly weight gain with atypical antipsychotics such as risperidone, a cautious approach is necessary. A second-generation antipsychotic like lamotrigine or quetiapine might be prescribed to stabilize mood with fewer weight-related adverse effects (Suppes et al., 2019). Additionally, addressing her hypothyroidism with levothyroxine, adjusting doses to maintain euthyroid state, may improve mood stability (Davies et al., 2016).

Psychotherapy and Nonpharmacologic Strategies

Cognitive-behavioral therapy (CBT) tailored for bipolar disorder can help Petunia recognize early warning signs of mood episodes, improve mood regulation, and address maladaptive thought patterns (Johnson & McKenzie, 2018). Psychoeducation about her condition and medication adherence is vital. Family therapy could involve her mother and brother to foster understanding and support. Psychoeducation on sleep hygiene and stress management are essential for mood stabilization.

Alternative and Complementary Therapies

Mindfulness-based interventions and omega-3 fatty acids have shown promise as adjuncts in mood disorder management (Szczepanik et al., 2018). Light therapy could be considered if seasonal mood fluctuations are evident.

Follow-Up and Monitoring

Regular psychiatric follow-up every 4-6 weeks initially, monitoring mood symptoms, medication side effects, thyroid function, and adherence is necessary. Self-report mood diaries and periodic lab assessments are recommended. Inclusion of a crisis intervention plan and safety measures, including a support system and emergency contact, are critical.

Health Promotion and Patient Education

Engaging Petunia in a health promotion activity such as a structured sleep hygiene program and encouraging participation in hobbies for stress relief are beneficial. Educating her about medication side effects, signs of relapse, and the importance of adherence enhances her engagement in treatment and early intervention.

Reflection

The analysis of Petunia's case highlighted the importance of integrating clinical history, observed behavior, and DSM-5 criteria for accurate diagnosis. I learned that distinguishing between mood episodes and mood disorders requires careful attention to episode duration, severity, and accompanying symptoms. I would emphasize a multidisciplinary approach, including psychoeducation, family involvement, and lifestyle modifications, to support long-term management.

Ethically, ensuring informed consent, respecting her autonomy, and addressing her concerns about medication side effects are vital. Social determinants such as her socioeconomic status and family dynamics influence her treatment adherence and recovery. Recognizing the role of her cultural background and personal values in her health behaviors guides more personalized care. Future care plans should incorporate culturally sensitive interventions, community resources, and health literacy support to promote sustained wellness and prevent relapse.

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5). Washington, DC: Author.
• Davies, J. M., et al. (2016). Thyroid disease and mood disorders: A review. Journal of Clinical Psychiatry, 77(4), 744–747.
• Johnson, S., & McKenzie, K. (2018). Psychotherapy for bipolar disorder: An evidence-based review. Bipolar Disorders, 20(2), 124–134.
• Lieb, K., et al. (2010). Borderline personality disorder. The Lancet, 376(9734), 471–482.
• Suppes, T., et al. (2019). Pharmacological management of bipolar disorder in adults: Consensus guidelines. Journal of Clinical Psychiatry, 80(1), 18a12507.
• Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
• Szczepanik, H., et al. (2018). Omega-3 fatty acids and mood disorders: A review. Nutrients, 10(8), 1174.
• Yatham, L. N., et al. (2018). Canadian Network for Mood and Anxiety Treatments guidelines for the management of bipolar disorder. Bipolar Disorders, 20(2), 97–170.
• Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.