Rewrite …………………attached must be original 

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: