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Discussion Topic 11 Mental Health Challenges

Discussion Topic 11 Mental Health Challenges

Sample Answer 

Discussion Topic 11 Mental Health Challenges

According to Santiago & Neto (2016), subjective and objective data are part of the SOAP standards for patient examination. In this case, the summary of the subjective and objective data for K.P. will be as follows:

Subjective:

Chief Complaint (CC): The patient reports feeling somewhat “down in the dumps” and sleepy at all times.

History of Present Illness (HPI): 48-year-old presenting with a six-week Hx of weight gain, constipation, appetite changes, concentration difficulties, and fatigue.

History: Denies feelings of suicidal ideations and mental treatment in the past. Also, does not enjoy her teaching job and has been experiencing irregular menstrual cycles.

Review of Systems (ROS): Although she answers questions slowly and her ‘affect’ is blunted, she is goal direct, oriented, and alert, with a clear speech.

Current Medications, Allergies: No allergies or medications.

Objective

Vital signs: Current weight is 155 Ibs.

Physical exam results: Slow response to questions, sluggish gait, dry skin, brittle nails, and thinning hair.

Labs: No labs.

Imaging results: No imaging results.

Other diagnostic data: No other diagnostics.

Besides subjective and objective data, I will add the assessment and the plan sections. The term SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan – a technique used in the documentation of patient information in an organized and structured manner (Podder, Lew, & Ghassemzadeh, 2020). I will use the assessment part to digest the objective and subjective information to get to the diagnosis. On the other hand, the plan will be critical in detailing the need for further testing as well as consultation with other healthcare providers.

Finally, according to Maung (2016), three types of differential diagnoses can be used to identify the patient’s actual condition, including a comparison of the symptoms complexes (which considers the signs and the symptoms presented by the patient as well as the chief complain), assessment of the local anatomic (which entails narrowing down to the specific anatomical system), and systems approach (a head-to-toe system evaluation). I will order a symptom evaluation as an initial diagnostic because it is the most effective for mental illnesses. The ICD guidelines use this approach to distinguish the different types of psychological diseases.

References

Maung, H. H. (2016). Diagnosis and causal explanation in psychiatry. Studies in History and Philosophy of Biological and Biomedical Sciences, 60, 15-24.

Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOPA notes. Florida, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/

Santiago, L. M., & Neto, I. (2016). SOAP methodology in general practice/family medicine teaching in the practice context. Acta Medica Portuguesa, 29(12), 854-859. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28425889

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Question 


Discussion Topic 11 Mental Health Challenges

***The initial discussion response should be in the range of 250-300 words. All questions in the topic must be addressed. All discussions need to be supported by a minimum of two scholarly resource. Journals and websites must be cited appropriately (Citation and reference must adhere to APA format). All components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with citations and references in APA format.

Case Study:

K.P. a 48-year-old woman presents to your primary care office with a 6-week history of fatigue, concentration difficulties, appetite changes, constipation, and weight gain. She reports feeling sleepy all the time and some what “down in the dumps.” She is a substitute teacher at the local public school and has had difficulty enjoying a job she has always “loved.” She decided to come in today because “something is wrong with me.” During this period, she has had irregular menstrual periods.

Examination

Discussion Topic 11 Mental Health Challenges

Discussion Topic 11 Mental Health Challenges

Findings from her physical exam reveal dry skin, thinning hair; brittle nails, sluggish gait, and slow response to questions. She has gained 20 lbs. since her last annual exam (last year 135 lbs. and today she weighs 155 lbs.). Although she answers questions slowly, she is alert and oriented, goal directed, and her speech is clear. Her affect is blunted. She denies a history of psychiatric treatment and suicidal ideations.

Questions:

  1. With the above information, construct the subjective and objective data in a SOAP Note format.
  2. Is there any other information that you would obtain to assist you in determining treatment options?
  3. Discuss the top three differential diagnoses.
  4. What initial diagnostics would you order?

Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with citations and references in APA format.

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