Video Transcript-
DR. MOORE: Good afternoon. I’m Dr. Moore. Want to thank you for coming
in for your appointment today. I’m going to be asking you some
questions about your history and some symptoms. And to get started,
I just want to ensure I have the right
patient and chart. So can you tell me your
name and your date of birth?
SHERMAN TREMAINE:
I’m Sherman Tremaine, and Tremaine is my game game. My birthday is November 3, 1968.
I’m Sherman Tremaine, and Tremaine is my game game. My birthday is November 3, 1968.
DR. MOORE: Great. And can you tell
me today’s date? Like the day of the week,
and where we are today?
me today’s date? Like the day of the week,
and where we are today?
SHERMAN TREMAINE: Use any recent
date, and any location is OK.
date, and any location is OK.
DR. MOORE: OK, Sherman. What about do you know
what month this is?
what month this is?
SHERMAN TREMAINE: It’s March 18.
DR. MOORE: And the
day of the week?
day of the week?
SHERMAN TREMAINE: Oh, it’s a
Wednesday or maybe a Thursday.
Wednesday or maybe a Thursday.
DR. MOORE: OK. And where are we today?
SHERMAN TREMAINE:
I believe we’re in your office, Dr. Moore.
I believe we’re in your office, Dr. Moore.
DR. MOORE: OK, great. So tell me a little bit about
what brings you in today. What brings you here?
what brings you in today. What brings you here?
SHERMAN TREMAINE: Well,
my sister made me come in. I was living with my
mom, and she died. I was living, and not bothering
anyone, and those people– those people, they just
won’t leave me alone.
my sister made me come in. I was living with my
mom, and she died. I was living, and not bothering
anyone, and those people– those people, they just
won’t leave me alone.
DR. MOORE: What people?
SHERMAN TREMAINE: The ones
outside my window watching. They watch me. I can hear them, and
I see their shadows. They think I don’t
see them, but I do. The government sent
them to watch me, so my taxes are high,
so high in the sky. Do you see that bird?
outside my window watching. They watch me. I can hear them, and
I see their shadows. They think I don’t
see them, but I do. The government sent
them to watch me, so my taxes are high,
so high in the sky. Do you see that bird?
DR. MOORE: Sherman,
how long have you saw or heard these people?
how long have you saw or heard these people?
SHERMAN TREMAINE: Oh, for weeks,
weeks and weeks and weeks. Hear that– hear that
heavy metal music? They want you to think
it’s weak, but it’s heavy.
weeks and weeks and weeks. Hear that– hear that
heavy metal music? They want you to think
it’s weak, but it’s heavy.
DR. MOORE: No, Sherman. I don’t see any birds
or hear any music. Do you sleep well, Sherman?
or hear any music. Do you sleep well, Sherman?
SHERMAN TREMAINE: I try to
but the voices are loud. They keep me up
for days and days. I try to watch TV, but they
watch me through the screen, and they come in
and poison my food. I tricked them though. I tricked them. I locked everything
up in the fridge. They aren’t getting in there. Can I smoke?
but the voices are loud. They keep me up
for days and days. I try to watch TV, but they
watch me through the screen, and they come in
and poison my food. I tricked them though. I tricked them. I locked everything
up in the fridge. They aren’t getting in there. Can I smoke?
DR. MOORE: No, Sherman. There is no smoking here. How much do you usually smoke?
SHERMAN TREMAINE: Well,
I smoke all day, all day. Three packs a day.
I smoke all day, all day. Three packs a day.
DR. MOORE: Three packs a day. OK. What about alcohol? When was your last drink?
SHERMAN TREMAINE: Oh, yesterday. My sister buys me a 12-pack,
and tells me to make it last until next week’s grocery run. I don’t go to the grocery store. They play too loud of
the heavy metal music. They also follow me there.
and tells me to make it last until next week’s grocery run. I don’t go to the grocery store. They play too loud of
the heavy metal music. They also follow me there.
DR. MOORE: What about marijuana?
SHERMAN TREMAINE: Yes,
but not since my mom died three years ago.
but not since my mom died three years ago.
DR. MOORE: Use any cocaine?
SHERMAN TREMAINE: No,
no, no, no, no, no, no. No drugs ever, clever, ever.
no, no, no, no, no, no. No drugs ever, clever, ever.
DR. MOORE: What about
any blackouts or seizures or see or hear things
from drugs or alcohol?
any blackouts or seizures or see or hear things
from drugs or alcohol?
SHERMAN TREMAINE: No, no, never
a clever [INAUDIBLE] ever.
a clever [INAUDIBLE] ever.
DR. MOORE: What about
any DUIs or legal issues from drugs or alcohol?
any DUIs or legal issues from drugs or alcohol?
SHERMAN TREMAINE:
Never clever’s ever.
Never clever’s ever.
DR. MOORE: OK. What about any medication
for your mental health? Have you tried those before, and
what was your reaction to them?
for your mental health? Have you tried those before, and
what was your reaction to them?
SHERMAN TREMAINE: I hate
Haldol and Thorazine. No, no, I’m not
going to take it. Risperidone gave me boobs. No, I’m not going to take it. Seroquel, that is OK. But they’re all poison,
nope, not going to take it.
Haldol and Thorazine. No, no, I’m not
going to take it. Risperidone gave me boobs. No, I’m not going to take it. Seroquel, that is OK. But they’re all poison,
nope, not going to take it.
DR. MOORE: OK. So tell me, any
blood relatives have any mental health or
substance abuse issues?
blood relatives have any mental health or
substance abuse issues?
SHERMAN TREMAINE:
They say that my dad was crazy with
paranoid schizophrenia. He did in the old
state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety.
They say that my dad was crazy with
paranoid schizophrenia. He did in the old
state hospital. They gave him his beer there. Can you believe that? Not like them today. My mom had anxiety.
DR. MOORE: Did any blood
relatives commit suicide? S
relatives commit suicide? S
HERMAN TREMAINE:
Oh, no demons there. No, no.
Oh, no demons there. No, no.
DR. MOORE: What about you? Have you ever done anything
like cut yourself, or had any thoughts about killing
yourself or anyone else?
like cut yourself, or had any thoughts about killing
yourself or anyone else?
SHERMAN TREMAINE:
I already told you. No demons there. Have been in the hospital three
times though when I was 20.
I already told you. No demons there. Have been in the hospital three
times though when I was 20.
DR. MOORE: OK. What about any medical issues? Do you have any
medical problems?
medical problems?
SHERMAN TREMAINE: Ooh, I
take metformin for diabetes. Had or I have a fatty
liver, they say, but they never saw it. So I don’t know unless
the aliens told them.
take metformin for diabetes. Had or I have a fatty
liver, they say, but they never saw it. So I don’t know unless
the aliens told them.
DR. MOORE: OK. So who raised you?
SHERMAN TREMAINE: My
mom and my sister.
mom and my sister.
DR. MOORE: And who
do you live with now?
do you live with now?
SHERMAN TREMAINE:
Myself, but my sister’s plotting with the
government to change that. They tapped my phone.
Myself, but my sister’s plotting with the
government to change that. They tapped my phone.
DR. MOORE: OK. Have you ever been married? Are you single,
widowed, or divorced?
widowed, or divorced?
SHERMAN TREMAINE: I’ve
never been married.
never been married.
DR. MOORE: Do you
have any children?
have any children?
SHERMAN TREMAINE: No.
DR. MOORE: OK. What is your highest
level of education?
level of education?
SHERMAN TREMAINE: I
went to the 10th grade.
went to the 10th grade.
DR. MOORE: And what do
you like to do for fun?
you like to do for fun?
SHERMAN TREMAINE: I don’t work,
so smoking and drinking pop.
so smoking and drinking pop.
DR. MOORE: OK. Have you ever been arrested or
convicted for anything legally?
convicted for anything legally?
SHERMAN TREMAINE: No, but
they have told me they would. They have told me they would
if I didn’t stop calling 911 about the people outside.
they have told me they would. They have told me they would
if I didn’t stop calling 911 about the people outside.
DR. MOORE: OK. What about any kind of trauma
as a child or an adult? Like physical, sexual,
emotional abuse.
as a child or an adult? Like physical, sexual,
emotional abuse.
SHERMAN TREMAINE: My dad was
rough on us until he died.
rough on us until he died.
DR. MOORE: OK. [MUSIC PLAYING] So thank you for answering
those questions for me. Now, let’s talk about
how I can best help you.
those questions for me. Now, let’s talk about
how I can best help you.
To Prepare
- 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: Sherman Tremaine. 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.
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 symptomology 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, and list them in order from highest priority to lowest 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.
- 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: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), 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.).
- Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
NRNP_6675_Week5_Assignment_Rubric
| Criteria | Ratings | Pts | ||||
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Create documentation in the Focused SOAP Note Template about your assigned patient.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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15 pts
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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
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15 pts
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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 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.
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20 pts
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In the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy.
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25 pts
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• Discussion include what may be done differently with this patient if student conducted the session again. Discussed the next intervention if you could follow up with this patient. The discussion was related to legal/ethical considerations (demonstrated critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that take into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
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5 pts
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Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
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10 pts
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Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list.
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5 pts
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Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation
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5 pts
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Total Points: 100
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