Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. 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) 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.).
Mood disorders are prevalent mental health conditions that significantly impact an individual’s emotional well-being and overall quality of life. This paper presents a comprehensive assessment and diagnostic process of a mock patient, Petunia Park, as portrayed in a video case study. The goal is to utilize the Focused SOAP (Subjective, Objective, Assessment, Plan) Note template to evaluate the patient’s condition, develop a differential diagnosis, and formulate an appropriate treatment plan. This analysis will also consider key factors such as mental status examination results, DSM-5-TR criteria, ethical considerations, and health promotion strategies.
The subjective assessment begins by collecting information from the patient regarding their chief complaint and symptomatology (Walden University, 2021). Petunia Park reported experiencing persistent sadness, loss of interest in previously enjoyed activities, low energy levels, poor concentration, and sleep disturbances. The duration of her symptoms has lasted for approximately six months, with increasing severity over time. These symptoms have significantly impacted her functioning in life, as she has withdrawn from social activities, struggled to maintain employment, and experienced strain in her interpersonal relationships.
During the psychiatric assessment, several observations were made. Petunia Park presented as a disheveled and emotionally distressed individual. She displayed psychomotor agitation, including fidgeting and restlessness. Her affect was consistently sad and flat throughout the assessment. Petunia Park exhibited slowed speech and difficulty maintaining eye contact. Additionally, her responses to questions were often tangential, further indicating impaired cognitive functioning (Walden University, 2021).
In the process of assessing Petunia Park’s mental health and well-being, we carefully considered the information gathered and explored several potential differential diagnoses:
Petunia Park exhibits numerous symptoms consistent with Major Depressive Disorder, as outlined in the DSM-5-TR (American Psychiatric Association, 2013). Her persistent low mood, pronounced loss of interest in previously enjoyed activities, disrupted sleep patterns, and impaired concentration all closely align with the diagnostic criteria for MDD. Furthermore, the observed psychomotor agitation, characterized by fidgeting and restlessness, could also be indicative of MDD. This aligns with the observation of a Walden faculty member assessing her in the case study video.
While Petunia Park’s symptoms predominantly suggest a mood disorder, it’s essential to consider the possibility of Generalized Anxiety Disorder (GAD) (American Psychiatric Association, 2013). Her presentation includes symptoms commonly associated with anxiety disorders, such as excessive worry, restlessness, and difficulty concentrating. Although these features often overlap with depression, they can also signify the presence of GAD, particularly when considering the duration of her distress.
Another potential diagnosis to consider is Dysthymic Disorder, characterized by a chronic, low-grade depressive mood that persists for at least two years (American Psychiatric Association, 2013). In Petunia Park’s case, her symptoms have been ongoing for approximately six months. While this duration doesn’t meet the threshold for Dysthymic Disorder, it’s essential to acknowledge it as a differential diagnosis given the extended period of emotional distress.
The selection of the primary diagnosis is a result of a comprehensive and meticulous critical-thinking process. It involves comparing the diagnostic criteria for each potential diagnosis and carefully evaluating the patient’s specific symptomatology. In this case, Petunia Park’s symptoms align most closely with Major Depressive Disorder, primarily due to the presence of hallmark depressive symptoms and the severity of functional impairment she is experiencing. This primary diagnosis serves as the cornerstone for developing an individualized and effective treatment plan tailored to her unique needs and challenges.
The treatment plan for Petunia Park includes both pharmacologic and non-pharmacologic interventions.
Petunia Park will be prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant, such as sertraline, at a therapeutic dose. This medication will help alleviate her depressive symptoms and improve her mood (American Psychiatric Association, 2013). It’s essential to monitor her closely for any potential side effects and adjust the medication as needed to ensure optimal outcomes.
Cognitive-behavioral therapy (CBT) will be initiated to address her negative thought patterns and provide coping strategies for managing her symptoms (Hofmann et al., 2012). This evidence-based therapeutic approach will help Petunia identify and challenge distorted thinking, develop healthier cognitive patterns, and acquire practical tools to manage her depression effectively. The therapy sessions will be scheduled regularly to track progress and make necessary adjustments.
Petunia Park will be encouraged to engage in regular physical exercise, which has been shown to have mood-lifting effects (Schuch et al., 2016). Incorporating exercise into her daily routine will not only improve her physical health but also boost her mental well-being. A customized exercise plan will be developed, taking into account her current fitness level and preferences.
Petunia Park will receive education on the importance of medication adherence, potential side effects of the antidepressant, and stress management techniques. It’s crucial for her to understand the role of medication in her treatment and be aware of any potential adverse effects. Additionally, she will be provided with strategies to cope with stress effectively, as stress management plays a significant role in managing mood disorders. This education will be ongoing, ensuring that Petunia is well-informed and empowered to take an active role in her treatment.
In reflecting on this case, several key points emerge:
Beyond the standard considerations of confidentiality and informed consent, it is essential to address Petunia Park’s autonomy in making treatment decisions. Informed consent should be an ongoing process, and her preferences and values should be respected throughout treatment (American Psychiatric Association, 2016). Furthermore, ethical considerations extend to maintaining a therapeutic alliance and addressing potential conflicts of interest that may arise during treatment.
Petunia Park’s socioeconomic status and limited access to mental health resources are important factors influencing her condition. Addressing these social determinants is critical for effective treatment (Adler et al., 2016). It is incumbent upon healthcare providers to explore the systemic barriers she faces, such as financial constraints, transportation issues, and the availability of affordable mental health services in her community.
Tailoring health promotion strategies to consider factors like age, cultural background, and socioeconomic status is crucial. Petunia Park’s individual needs and risk factors should guide health promotion efforts (Pampel et al., 2010). This includes encouraging lifestyle changes that promote overall well-being, such as stress management techniques, healthy dietary choices, and regular physical activity, all of which can complement her treatment plan and foster recovery.
Assessing, diagnosing, and treating mood disorders require a thorough understanding of the patient’s history, symptoms, and context. In Petunia Park’s case, Major Depressive Disorder was identified as the primary diagnosis, and a comprehensive treatment plan was developed. The role of ethical considerations, social determinants of health, and individualized health promotion strategies cannot be underestimated in providing holistic care for individuals with mood disorders. This case study underscores the importance of a person-centered approach to mental health assessment and treatment.
