NUR 635 CLC – Psychiatric Case Study

NUR 635 CLC – Psychiatric Case Study

Assessment Description

This is a Collaborative Learning Community (CLC) assignment. 

The purpose of this assignment is to apply a systematic and defendable approach to the administration of psychiatric medications by completing a comprehensive, individualized assessment of patient needs to determine the appropriate course of action.

Develop a 15-20-slide PowerPoint presentation within your CLC group that will be presented in SOAP note format, communicating in a manner that facilitates a partnership approach to quality health care delivery. Utilize topic Resources for assignment references. 

Initial Patient Assessment

Patient Brian Jones is a 36-year-old male who comes to your clinic with a complaint of mild-to-moderate depression for the past four months. He reports he has been going to see his behavioral therapist, which does help; however, he still is experiencing depression. On exam he is overweight and complains of insomnia.

As the provider, you order laboratory studies and EKG. The patient has no history of suicidal ideation and has never been hospitalized for any psychiatric disorder. He states that he is functioning well in his job but struggles with personal relationships.

Brian’s main complaints are depression and insomnia. He does not report anxiety or panic attacks and denies any current or past history of drug or tobacco use. The patient is relatively healthy, has received regular medical care, and does not take any other medications.

Two-Week Follow-Up

Brian comes back to the clinic in two weeks and reports that his sleep has improved, and he is not experiencing any side effects from the medication. He is instructed to follow up in four more weeks to determine if the medications are helping his mood, which he states has not improved. He will continue working with his therapist weekly.

One-Month Follow-Up

After another month, Brian returns to the office. He still describes his mood as “depressed.”

Two-Month Follow-Up

When Brian returns one month later, he states that his mood has improved, and he is more comfortable about going out in public and socializing. However, he reports he is now experiencing sexual side effects (erectile dysfunction).

Final Check-In

In another month, Brian reports that his depression is gone, and he is now sleeping 6-8 hours per night. He is no longer having side effects from medications, and even reports that he has lost weight, which he attributes to an increase in energy.

Utilizing information provided, present the following information in a SOAP note format:

  • Document a History of Present Illness (HPI) utilizing OPQRST.

Onset: when did symptoms start

Precipitants: events, drugs, alcohol, etc.

Quality: character of the symptom(s)

Radiation: any associated symptoms

Severity: impact on patient’s life, daily functioning, family and friends

Timing: intermittent vs constant; what makes it better? Worse?

  • Document the patient’s social history, improvising any information that is not provided to construct a thorough history.
  • Document your assessment of this patient. Provide appropriate diagnosis, along with corresponding ICD-10 code. Include a minimum of two differential diagnoses, and explain how the provider will rule these out.
  • Which medication is appropriate to start Brian on after the initial assessment? Explain your rationale.
  • At the two-week follow-up, would it be appropriate to add, change or maintain medications?
  • At the one-month follow-up, as the practitioner, what instructions do you give the patient regarding his dosage? Explain your rationale.
  • At the two-month follow-up, as the practitioner, what options are given to the patient regarding his medication management? Justify your decision.
  • At the final check-in, document the final plan for this patient, including medication instructions, education, and when to follow up.

Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center 

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 6.1