Assignment 2 Focused SOAP Note and Patient Case Presentation
For this Assignment, you will document information about a patient that you examined during the last 3 weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient. Be sure to incorporate any feedback you received on your Week 3 and Week 7 case presentations into this final presentation for the course.
- 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 or adolescent patient that you examined during the last 3 weeks who presented with a disorder for which you have not already created a Focused SOAP Note in Weeks 3 or 7. (For instance, if you selected a patient with anorexia nervosa in Week 7, you must choose a patient with another type of disorder for this week.)
- Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
- All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
- When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
- You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
- Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
- Ensure that you have the appropriate lighting and equipment to record the presentation.
Record yourself presenting the complex case for your clinical patient.
Do not sit and read your written evaluation! The video portion of the assignment is a simulation to demonstrate your ability to succinctly and effectively present a complex case to a colleague for a case consultation. The written portion of this assignment is a simulation for you to demonstrate to the faculty your ability to document the complex case as you would in an electronic medical record. The written portion of the assignment will be used as a guide for faculty to review your video to determine if you are omitting pertinent information or including non-essential information during your case staffing consultation video.
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).
- 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.
- 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.
- 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 three 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 supported by the patient’s symptoms.
- Plan: In your video, describe your treatment plan using clinical practice guidelines supported by evidence-based practice. Include a discussion on your chosen FDA-approved psychopharmacologic agents and include alternative treatments available and supported by valid research. All treatment choices must have a discussion of your rationale for the choice supported by valid research. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this treatment session?
- In your written plan include all the above as well as include one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
- Reflection notes: What would you do differently with this patient if you could conduct the session over? 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.
Expert Answer and Explanation
CC (chief complaint): “I tremble a lot when in front of my classmates.”
HPI: AA is a 13-years-old boy of African American brought to the psychiatric mental health practitioner (PMHP) for a complaint of excessive trembling in front of his classmates. The patient’s mother noted that his teacher called that reported that AA never speaks when in front of the class and rarely speaks to people.
The patient noted that he always experiences extreme fear when he is exposed to unfamiliar situations. He cannot eat or drink in public including in his class. He does not eat at the dining hall for fear of being embarrassed by peers. The patient noted that he once had extreme feelings of fear when he was tasked by his teacher to give a speech in front of his class.
He noted that he urinated on himself when in front of classmates when asked to make a speech about the environment. The patient’s mother noted that the patient always cries when faced with social situations such as birthdays. For instance, she froze and failed to speak in front of her peers during her last birthday party. “I do not like to be in social situations such as parties or class presentations.” He has been experiencing anxiety for three years now. The fear of social situations has greatly impacted his performance and interactions with peers.
Substance Current Use: No history of drug or alcohol use.
Medical History: Never diagnosed with mental health issues. No medical problems.
- Current Medications: No current medications.
- Allergies:No environmental, drug, or food allergies.
- Reproductive Hx:No reproductive issues.
- GENERAL: No fever, chills, and change in appetite. No changes in weight.
- HEENT: Eyes: No blurred vision or other visual problems. Ears: No hearing issues. Nose: No runny nose or stuffy nose. Throat: No sore throat.
- SKIN: No rashes or sores.
- CARDIOVASCULAR: No chest pain, chest discomfort, or chest pressure. No edema.
- RESPIRATORY: No shortness of breath or sputum.
- GASTROINTESTINAL: NO vomiting, anorexia, diarrhea, or nausea. No abdominal blood or pain. The patient complains of stomach aches, especially when extremely anxious.
- GENITOURINARY: No burning or urination or urinary tract disorder.
- NEUROLOGICAL: No syncope, dizziness, headache, ataxia, paralysis, or numbness or tingling in the extremities.
- MUSCULOSKELETAL: No back pain, muscle, or joint stiffness or pain.
- HEMATOLOGIC: No bleeding or amenia.
- LYMPHATICS: No history of splenectomy.
- ENDOCRINOLOGIC: No reports of heat or cold intolerance. No polyuria or polydipsia.
Vital Signs: BP 107/72, RR 18, P 68, Ht’ 5’1, Wt. 45kgs, Temp 35.8
- HEENT: Noncontributory.
- Skin: No rash or itching.
- Cardiovascular: No chest walls or cracks. Regular heart rate or rhythm. No edema.
- Respiratory: No breathing distress, no fluids in the lungs, no wheezing, no inspiratory crackles, no crackles.
- Gastrointestinal: The patient
- Social Phobia Inventory: This tool is used to evaluate and screen patients for social anxiety disorder. Mörtberg and Jansson Fröjmark (2019) noted that the tool is valid and reliable for screening patients of all ages.
- Blood tests: Blood tests will be needed to rule out any infection that might cause stomach pains.
Mental Status Examination: The patient appears well-groomed and dressed. He is oriented to place, people, and time. His mood is euthymic and his affect is consistent with his mood. Speech is slow. He answers questions correctly but takes time. Eye conduct is furtive. He denies hallucinations, illusions, or delusional thinking. His attitude changes with the environment. His insight and judgment are fair. He loses attention and concentration when in a social environment. He denies suicidal or homicidal thoughts. His memory is intact.
- Social Anxiety Disorder (SAD) (Social Phobia) DSM-5 300.23 (F40.10). The primary diagnosis for this case is SAD. Koyuncu et al. (2019) noted that patients with social phobia often experience extreme fear or anxiety when in social situations, such as presenting in public. According to American Psychiatric Association (2013), patients with SAD fear specific social settings where they feel they can be observed, noticed, or scrutinized. Individuals with the disorder also fear social settings where they feel they will be socially rejected. Social interaction in patients with SAD trigger distress. the fear should persist for six months or so. The patient experiences the symptoms highlighted in the DSM-5, making it the primary diagnosis.
- Panic Disorder DSM-5 300.01 (F41.0): Panic disorder is an anxiety disorder characterized by panic attack episodes, which are unexpected or recurrent (Baroni et al., 2021). Patients who have had a single panic attack often spend a month or so fearing situations that might cause the attack again (APA, 2013). This disorder can be included in the diagnosis because the patient has anxiety but has been ruled out because he has not reported any panic attacks.
- Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41.1): The last diagnosis is GAD. GAD has been included in the diagnosis because the patient often experiences uncontrol and extreme fear or anxiety (Sapra et al., 2020). However, it has been ruled out because the patient’s anxiety and fear are mostly triggered by social settings, making it a social phobia (APA, 2013).
The case might be complex to diagnose. However, DSM-5 can be used to identify the exact cause of the patient’s symptoms. The patient has SAD as per DSM-5 criteria. If the current treatment does not work, I would suggest that medication be combined with psychotherapy.
Case Formulation and Treatment Plan:
Based on the physical and mental exam and patient assessment, the patient might have SAD. His anxiety symptoms are triggered when he faces social situations, such as presenting in class or eating in front of people. He can be treated using Social Effectiveness Therapy for Children and Adolescents (SET-C). The therapy is designed for teens and children. it uses peer generalization, exposure therapy, and group social skills (Alvarez et al., 2018). The therapy has successfully improved social skills, decreased social anxiety, and help teens improve their friendship (Alvarez et al., 2018).
Alvarez, E., Puliafico, A., Leonte, K. G., & Albano, A. M. (2018). Psychotherapy for anxiety disorders in children and adolescents. https://www.medilib.ir/uptodate/show/15927
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition).
Baroni, M., Frumento, S., Cesari, V., Gemignani, A., Menicucci, D., & Rutigliano, G. (2021). Unconscious processing of subliminal stimuli in panic disorder: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 128, 136-151. https://doi.org/10.1016/j.neubiorev.2021.06.023
Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context, 8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448478/
Mörtberg, E., & Jansson Fröjmark, M. (2019). Psychometric evaluation of the social phobia inventory and the mini-social phobia inventory in a Swedish university student sample. Psychological Reports, 122(1), 323-339. https://doi.org/10.1080/07481756.2018.1435188
Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using generalized anxiety disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus, 12(5). https://www.cureus.com/articles/31476-using-generalized-anxiety-disorder-2-gad-2-and-gad-7-in-a-primary-care-setting
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