Assessment For a Patient With Dementia Discussion
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Focused SOAP Note Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. After reviewing full details of the rubric, you can use it as a guide. Assessment For a Patient With Dementia Discussion
In the Subjective section, provide:
- Chief complaint
- History of present illness (HPI)
- Past psychiatric history
- Medication trials and current medications
- Psychotherapy or previous psychiatric diagnosis
- Pertinent substance use, family psychiatric/substance use, social, and medical history
- Allergies
- ROS
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Read rating descriptions to see the grading standards!
In the Objective section, provide:
- Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
- Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
Read rating descriptions to see the grading standards!
In the Assessment section, provide:
- Results of the mental status examination, presented in paragraph form.
- At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR 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.
- Read rating descriptions to see the grading standards!
Reflect on this case. Include: 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 taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). Assessment For a Patient With Dementia Discussion
(The FOCUSED SOAP psychiatric evaluation is typically the follow-up visit patient note. You will practice writing this type of note in this course. You will be focusing more on the symptoms from your differential diagnosis from the comprehensive psychiatric evaluation narrowing to your diagnostic impression. You will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
Subjective:
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:
N.M. is a 34-year-old Asian male presents for medication management follow up for anxiety. He was initiated sertraline last appt which he finds was effective for two weeks then symptoms began to return.
Or
P.H., a 16-year-old Hispanic female, presents for follow up to discuss previous psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications as we deferred until further testing and screening was conducted.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. First what is bringing the patient to your follow up evaluation? Document symptom onset, duration, frequency, severity, and impact. What has worsened or improved since last appointment? What stressors are they facing? Your description here will guide your differential diagnoses into your diagnostic impression. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products. Assessment For a Patient With Dementia Discussion
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: Cover all body systems that may help you include or rule out a differential diagnosis. Please note: THIS IS DIFFERENT from a physical examination!
You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness, or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective:
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Assessment:
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form. Assessment For a Patient With Dementia Discussion
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.). Assessment For a Patient With Dementia Discussion
Case Formulation and Treatment Plan
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions including psychotherapy and/or psychopharmacology, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *See an example below. You will modify to your practice so there may be information excluded/included. If you are completing this for a practicum, what does your preceptor document?
Risks and benefits of medications are discussed including non- treatment. Potential side effects of medications discussed (be detailed in what side effects discussed). Informed client not to stop medication abruptly without discussing with providers. Instructed to call and report any adverse reactions. Discussed risk of medication with pregnancy/fetus, encouraged birth control, discussed if does become pregnant to inform provider as soon as possible. Discussed how some medications might decreased birth control pill, would need back up method (exclude for males). Assessment For a Patient With Dementia Discussion
Discussed risks of mixing medications with OTC drugs, herbal, alcohol/illegal drugs. Instructed to avoid this practice. Encouraged abstinence. Discussed how drugs/alcohol affect mental health, physical health, sleep architecture.
Initiation of (list out any medication and why prescribed, any therapy services or referrals to specialist):
Client was encouraged to continue with case management and/or therapy services (if not provided by you)
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PMP report (only if actually completed)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (this relates to informed consent; you will need to assess their understanding and agreement)
Follow up with PCP as needed and/or for:
Labs ordered and/or reviewed (write out what diagnostic test ordered, rationale for ordering, and if discussed fasting/non fasting or other patient education)
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care. Assessment For a Patient With Dementia Discussion
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
Patient Information: The patient’s name is PP, she is a female and is 25 years old.
Subjective:
CC (chief complaint): The patient goes to the healthcare facility with the main aim of undergoing a healthcare assessment claiming that she has been under medications but has recently stopped them because they have a negative effect in her and she feels they have been squashing her personality and they have not been helping her.
HPI: Petunia Park is a 25-year-old patient who goes to the hospital for a mental health assessment. She tests positive for depression and she has been taking different medications and has recently stooped them since they have been squashing her personality and she feels that she does not need them. She has also stopped taking the medication since she feels she does not need them. Nevertheless, these medications have not effectively managed the clinical symptoms she is facing and she has been unwilling to continue with the medication.
Substance Current Use: The patient claims that before, she tried taking alcohol but never had a good experience with it and she stopped taking it. She also tried other drugs like Marijuana and Cocaine but she stopped taking them and has never even thought if trying them. Currently, she has been taking nicotine and shows lack of willingness in stopping taking it. Assessment For a Patient With Dementia Discussion
Medical History:
- Current Medications: Currently, she is taking medications to help in managing hypothyroidism. She is also taking birth control pills for polycystic ovaries and medications to manage depression. However, she does not recall the name of the medications but she only remembers that they begin with letter “L.”
- Allergies: The patient has no known allergies to any food or drugs.
- Reproductive Hx: Petunia Park claims that she has a boyfriend and despite this, she loves going out and even having casual sex with her friends. She claims that the sex she has with other men is done in a safe way and does not place her at any risk.
ROS:
- GENERAL: The client is very talkative and she is in good health.
- HEENT: Petunia Park lacked any abnormal presentations in the throat, nose, ears, and eyes meaning that there was no concern in her health.
- SKIN: She lacks any rashes or bruises on the skin.
- CARDIOVASCULAR: The lungs and heart were normal.
- RESPIRATORY: The patient did not show any signs of shortness of breath or breathlessness.
- GASTROINTESTINAL: There were none of the abdominal concerns such as vomiting, nausea and abdominal pain.
- GENITOURINARY: Petunia Park has no abnormal presentation or infection in the genitourinary system.
- NEUROLOGICAL: Throughout the interview, the client was alert.
- MUSCULOSKELETAL: The patient did not experience any joint or muscular inflammation.
- HEMATOLOGIC: The patient did not have any anemia or blood abnormalities.
- LYMPHATICS: The lymph nodes were not inflamed.
- ENDOCRINOLOGIC: The patient did not have any endocrinology conditions. Even if it was clear that the patient took medications for hypothyroidism. Assessment For a Patient With Dementia Discussion
Objective:
Diagnostic results: The patient did not go through any laboratory tests but he was treated based on the DSM-5 diagnostic criteria.
Primary Diagnosis: The patient suffers from bipolar II disorder and its ICD 10-CM code is F31.81. The DSM 5 criteria shows that a patient ha smajor depressive disorder which is succeeded by a hypomania episode. The mood oscillates between the two different oresnetations. The patients gets the aggressive tendencies of getting easily attracted and an increase focus towards euphora, the gaols and thoughts which can be considered to be unusually rushed. In such case, the patient had most symptoms even if she was told that she had depression previously.
Differential Diagnoses:
Depression: This is a condition that affects an individual by having an episode of persistent low moods, which is accompanied by feelings of guilt and worthlessness. The condition is under the code ICD 10 and F33.0 (Park & Zarate, 2019). The patient can present suicidal ideations while others may not try attempting suicide. The condition can be seen from the DSM-5 category and an individual loses interest in the life activities that they were previously used to. In this case, the client has several presentations of low mood and there were times when she was overly active and full of energy (Park & Zarate, 2019). It would also be ruled out that it never meets the DSM 5 criteria since the client never lost interest in social activities, and had no suicidal ideations but he only felt as if he has no mood to do anything. Assessment For a Patient With Dementia Discussion
Hypothyroidism: The patient undergoes unspecified presentation related to the condition in E03.9 in ICD 10. Its clinical features include psychological symptoms like depression, thought processes, slow movement, weight gain and tiredness (Chovato et al., 2019). The patient also experienced a decreased attention span, hypersomnia, lethargy, sleep apnea, and instability with the psychotic symptoms. There are no right symptom presentations that is the patient’s primary diagnosis (Chiovato et al., 2019). The patients lack intolerance to cold that was detected and the patients have alternating energy points and mood as a possible alternative for the diagnosis. For example, the patient does not show hypersomnia patients but it is indicated that she goes for long days without sleep. Assessment For a Patient With Dementia Discussion
Schizophrenia: The patients undergo an unspecified presentation and Schizophrenia is ICD 10 code in F20.9. The clients suffering from this condition have clinical symptoms like gross disorganization, disorganized speech, delusions, hallucinations and even catatonic behavior. The patients also experience an altered view of the world and how things should be done (McCutcheon et al., 2020). The client also shows auditory hallucinations and initially, the symptoms are most frequent for the patient to undergo a diagnosis and there are no symptoms she presents with that show there is an alternative diagnosis.
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Assessment:
Mental Status Examination: Petunia Park was well oriented in terms of the place, time, and people in the onset of the interview. The patient was correctly dressed and responded to the questions well. She also asked questions to the healthcare provider and his speech was coherent with the audible volume, and tone even if some questions irritated her. She was charmed and seemed to be lively when giving a response to the questions asked. Her memory was intact even if she pointed out an auditory hallucination before.
Diagnostic Impression: Petunia Park has bipolar II disorder with an ICD 10-C, code in 31.81. Based on the DSM 5 criteria, the patient would present one major depressive episode which is succeeded by a hypomania episode making the mood to oscillate between the two different presentations. The patients would also get distracted easily, experience aggressive tendencies, euphoria, increased focus on her goals and have a thinking that is often rushed. From the case interview, Petunia Park has most symptoms of depression as she had in the previous hospital visit. Assessment For a Patient With Dementia Discussion
Reflections: Before, the client was diagnosed with depression and he was given medications which never made any impact on him. The previous diagnosis was not comprehensive to cover any fluctuations in her mood and the suboptimal results she had. Everything could be done differently and I would examine the patient to determine the causes of the other presentations she was experiencing instead of volunteering. The current diagnosis is accurate and it would increase the possibility of helping Petunia Park to manage her condition well.
Case Formulation and Treatment Plan: It would have been necessary for the healthcare professional to give Petunia Park Lithium. Lithium is an effective mood stabilizer given to bipolar patients. It would be crucial to enroll the patients on counseling to facilitate behavioral change, which would assist her in correctly managing the condition. Improving her health would be vital in urging the patients to avoid substance use as the prolonged use that would open room for another. It would be right to educate her on the importance of complying to treatment and improving on the presentation. Assessment For a Patient With Dementia Discussion