Comprehensive Focused SOAP Psychiatric Evaluation Discussion

Week 7: Personality and Paraphilic Disorders
What do I have to do? When do I have to do it?
Review your Learning Resources.
Days 1–7
Grand Rounds Discussion: Complex Case Study Presentation
Presenters post their videos by Day 3. Participants continue the discussion through Day 7. Comprehensive Focused SOAP Psychiatric Evaluation Discussion

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Assignment: Clinical Hour and Patient Logs
Record your clinical hours and patient encounters in Meditrek.
At your practicum site, you have been strengthening your communication, assessment, diagnostic reasoning, and treatment planning skills. This week, you highlight these skills as you participate in a Grand Rounds Discussion, just as you did in Week 4. The Grand Rounds put presenters in the facilitator role, allowing each of you a turn to demonstrate your clinical leadership skills as you bridge to advanced practice nursing in this, your final practicum course. You also continue to track your clinical time and patients in Meditrek.
Learning Objectives
Students will: Comprehensive Focused SOAP Psychiatric Evaluation Discussion
Describe clinical hours and patient encounters
Assess and diagnose patients in mental health settings*
Develop plans of care for patients in mental health settings*
Develop a case study presentation based on a clinical patient*
Analyze cases involving advanced practice care of patients in mental health settings
Advocate health promotion and patient education strategies across the lifespan
*This week\’s presenters only
Learning Resources
Required Readings (click to expand/reduce)
Recommended Readings (click to expand/reduce)
Recommended Media (click to expand/reduce)
Grand Rounds Discussion: Complex Case Study Presentation

Photo Credit: [RGtimeline]/[iStock / Getty Images Plus]/Getty Images
This week you participate in the second of three clinical discussions called grand rounds. In one of these 3 weeks, you will be a presenter as well as help facilitate the online discussion; in the others you will be an active discussion participant. When it is your week to present, you will create a focused SOAP note and a short didactic (teaching) video presenting a real (but de-identified) complex patient case from your practicum experience.
You should have received an assignment from your Instructor letting you know which week of the course you are assigned to present.
To prepare: Comprehensive Focused SOAP Psychiatric Evaluation Discussion
Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
Select a child/adolescent patient from your clinical experience that presents with a significant concern. Create a focused SOAP note for this patient using the template in the Resources. All SOAP notes must be signed, and each page must be initialled by your Preceptor. When you submit your SOAP note, you should include the complete SOAP note as a Word document and PDF/images of each page that is initialled and signed by your Preceptor. You must submit your SOAP note using Safe Assign Comprehensive Focused SOAP Psychiatric Evaluation Discussion.
Please Note: Electronic signatures are not accepted. If both files are not received by the due date, Faculty will deduct points per the Walden Late Policies.
Then, based on your SOAP note of this patient, develop a video case study presentation. Set aside time to practice what you will say beforehand and ensure that you have the appropriate lighting and equipment to record the presentation.
Your presentation should include objectives for your audience, at least three possible discussion questions/prompts for your classmates to respond to, and at least five scholarly resources to support your diagnostic reasoning and treatment plan.
Video assignment for this week’s presenters:
Record yourself presenting the complex case study for your clinical patient. In your presentation:
Dress professionally and present yourself in a professional manner.
Display your photo ID at the start of the video when you introduce yourself.
Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
State 3–4 objectives for the presentation that are targeted, clear, use appropriate verbs from Bloom’s taxonomy, and address what the audience will know or be able to do after viewing.
Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management. Comprehensive Focused SOAP Psychiatric Evaluation Discussion

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Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
Pose three questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.
Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
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 their mental status examination results. What were your differential diagnoses? Provide a minimum of 3 possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis, and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Plan: What was your plan for psychotherapy (include one health promotion activity and patient education)? What was 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.
Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow-up, discuss what your next intervention would be Comprehensive Focused SOAP Psychiatric Evaluation Discussion.

Objectives for the presentation
1. To define personality and paraphilic disorders
2. To apply the learned concepts in a case study for paraphilic and personality disorder
3. To evaluate the treatment options for paraphilic and personality disorders.
Introduction
Mental health disorders are characterized by disturbance in an individual’s cognition, emotional regulation, and/ or behaviour. There are different types of mental health disorders that can cause such disturbance. A personality disorder is a mental illness where an individual develops rigid and unhealthy thinking and functional and behavioural patterns. Paraphilias are intense sexual interests, fantasies urge, or behaviours that are persistent and involve atypical objects, activities, or situations to derive sexual pleasure (Fisher & Marwaha, 2022)Comprehensive Focused SOAP Psychiatric Evaluation Discussion. The case study below will provide further insight into the management of these conditions.
Subjective Data
Chief Complaint
The patient complained of insatiable sexual drive which had lasted for over the past six months and attempted sexual involvement with a neighbour, asking him to inflict pain on her so that she could attain sexual pleasure.
History of presenting illness
The patient was brought to the hospital by her parents. It was reported that she had been sexually hyperactive and had attempted to have sexual intercourse with a neighbour who she informed to tie her up for the act. The patient reported having intense sexual arousal which had lasted for the past six months with sexual fantasies and urges. On examination, the patient was hyper-talkative with delusions of grandeur and very irritable. She reported having an insatiable sexual drive towards the neighbour she had attempted to have sex with and also claimed that her mother had attempted to poison her. The patient reported having intense sexual arousal which had lasted for the past six months with sexual fantasies and urges. She also reported deriving sexual satisfaction from intense pain and preferred having whips and other pain-inflicting objects to get sexual satisfaction.
These symptoms were affecting her normal functioning because she could not concentrate in class, her relationship with her classmates, friends, and teachers was affected, and she was also suspicious of her mother, causing strain in their relationship.
Current Substance Use
She reported being an occasional drinker and smoker.
Medical History
The patient had never been admitted for any medical condition, no history of surgical operations or blood transfusions.

Current medications
No current medications.
Allergies
There were no known food and drug allergies.
Reproductive history
Menarche began 5 years ago and is regular lasting 4 days. The patient reported being sexually active.
REVIEW OF SYSTEMS
General Appearance
On admission, the patient was generally unkempt with long nails and shaggy hair. She was a 17-year-old African American female with a weight of 55kg. Appeared well nourished. She had some scars on the face which she reported to be self-inflicted.
Head
The patient had shaggy hair, with swelling on the scalp.
Eyes
No eye discharge, no loss of vision, does not use glasses or contact lenses, No signs of jaundice or parlours Comprehensive Focused SOAP Psychiatric Evaluation Discussion.

Ears
No hearing loss, otorrhea absent, no tinnitus.
Nose
No epistaxis, no rhinorrhoea.
Throat
No soreness of the throat was reported, no oral sores or lesions, and gingivitis was absent.
Integumentary System and Breast
There were no skin rashes. The patient had some injury marks on her left arm which she reported to have been caused when she fell on the tarmac during one of her drinking episodes. No pruritus, no breast lumps, no breast pain, and nipple discharge absent. No hair loss from the skin (alopecia)Comprehensive Focused SOAP Psychiatric Evaluation Discussion.
Cardiovascular System
The patient reported no chest pains, no palpitations, no oedema in the legs, and no leg pain when walking.
Respiratory System
No cough, no wheezes on auscultation, no shortness of breath.
Gastrointestinal System
No nausea or vomiting. However, the patient reported a loss of appetite. There was no report of diarrhea or constipation. No abdominal pain.
Genitourinary
No pelvic pain, no burning with urination, reports no urinary frequency, and no incontinence. Reported having been treated for syphilis two years ago. She had her last menstrual flow two weeks ago. No vaginal bleeding.
Neurological System
Reported no headache, no muscle weakness, or numbness. Memory was intact.
Musculoskeletal System
No abnormalities were detected.
Hematologic System
She had a random blood sugar of 4.5 mmol/L
Lymphatic System
No palpable lymph nodes
Endocrinological System
No heat intolerance, polydipsia, or polyphagia.
Objective data
Diagnostic Results
The patient was tested for sexually transmitted infections including HIV, syphilis, and gonorrhoea. All were found to be negative.
MOST RECENT MENTAL STATUS EXAMINATION
The patient appeared unkempt having refused to comb her hair and cut her nails short. She was heavily dressed which is inappropriate for the weather. She had a straight posture with well-coordinated movement. She was cooperative but hyperactive with pressured speech. She had a euphoric mood. She had a labile affect, which was congruent with the mood. In her thought process, she had tangentiality and included trivial details in her speech that were unnecessary Comprehensive Focused SOAP Psychiatric Evaluation Discussion.
She had persecutory delusions, with a strong belief that her mother wanted to poison her. She also had delusions of grandeur, claiming to be in control of her situation and that there was nothing that she could not treat herself because she was a doctor. She believed that her neighbour with whom she tried to have sex was in love with her and that he had tried to send coded messages to her to which she replied. She had no hallucinations. She was well oriented to time, place, person, and identity. She had a relatively good immediate retention and recall memory, intact recent memory, and remote memory with a good fund of knowledge.
Her concentration was poor but had good judgment. Her insight was at level 1 because she did not believe that she needed any medical attention. She had a relatively reduced appetite, and poor sleep pattern because of hyperactivity with a very high libido and sexual urge. Reported masturbating while thinking about her neighbour. She had very high energy levels.

Diagnostic Impression
My diagnosis for this patient was paraphilia, particularly sexual masochism due to her intense sexual urge and increased libido. She reported deriving sexual satisfaction from intense pain and prefers having whips and other pain-inflicting objects to get sexual satisfaction.
Differential Diagnosis
Some of the differential diagnoses for this patient included bipolar mood disorder because of her hyperactivity and intense energy (Soreff, 2019)Comprehensive Focused SOAP Psychiatric Evaluation Discussion. Paranoid personality disorder was also another differential diagnosis because the patient appeared suspicious of the mother claiming an attempt to poison her. My last differential diagnosis was schizophrenia because of her delusions of grandeur, erotomania, and persecution.
My primary diagnosis for this patient was consistent with DSM-5 criteria because the patient had these intense sexual urges over the past six months and derived sexual pleasure from painful stimulation, which could not be considered normal.
Treatment Plan
The treatment plan was to treat the patient with mood stabilizers, particularly valproic acid and carbamazepine to reduce the intense energy levels and also reduce the delusions. Psychotherapy was also provided to determine the underlying cause of the behaviour. Other alternative treatment options which were explored include the imagery desensitization technique where the patient was told to imagine herself participating in masochism and then experience a negative event with the aim of reducing future desire to participate in the act.

Nursing Reflection
In my follow-up care for the patient three weeks later, she was doing considerably well and reported having reduced energy levels. Her delusions had subsided and she reported having a lesser desire for masochism. She also had an improved relationship with her mother. I advised her to continue seeing her therapist help her fully recover. I believe that with continued counselling and behavioural therapy, she will show a considerable improvement and reduction in her symptoms Comprehensive Focused SOAP Psychiatric Evaluation Discussion.

References
Fisher, K.A., & Marwaha, R. (2022). Paraphilia. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK554425/#:~:text=Paraphilias%20are%20persistent%20and%20recurrent,that%20are%20atypical%20in%20nature.

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Labrecque, F., Potz, A., Larouche, M., & Joyal, C. C. (2020). What Is So Appealing About Being Spanked, Flogged, Dominated, or Restrained? Answers from Practitioners of Sexual Masochism/Submission. The Journal of Sex Research, 58(4), 409–423. https://doi.org/10.1080/00224499.2020.1767025
Soref, S. (2019). How is bipolar affective disorder (manic depressive illness) characterized?. Retrieved 13th July 2022 from https://www.medscape.com/answers/286342-101507/how-is-bipolar-affective-disorder-manic-depressive-illness-characterized#:~:text=Bipolar%20disorder%20is%20characterized%20by,irritable%20mood%20known%20as%20mania.
Brown, A., Barker, E. D., & Rahman, Q. (2019). A Systematic Scoping Review of the Prevalence, Etiological, Psychological, and Interpersonal Factors Associated with BDSM. The Journal of Sex Research, 57(6), 781–811. https://doi.org/10.1080/00224499.2019.1665619 Comprehensive Focused SOAP Psychiatric Evaluation Discussion