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[ANSWERED OCTOBER 2022] PRAC 6540 Week 4 Discussion; Grand Rounds Complex Case Study Presentation

PRAC 6540 Week 4 Discussion; Grand Rounds Complex Case Study Presentation

In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three 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: 

  • Review this week’s Learning Resources and consider the insights they provide. Select a child/adolescent or adult 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.
  • Then, based on your SOAP note of this patient, develop a video case study presentation.
  • Your presentation should include objectives for your audience, at least 3 possible discussion questions/prompts for your classmates to respond to, and at least 5 scholarly resources to support your diagnostic reasoning and treatment plan.
  • 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.
  • 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 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 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.

Rubric Detail

  Excellent Good Fair Poor
Photo ID Display and Professional Attire 5 (5%) – 5 (5%)

Photo ID is displayed. The student is dressed professionally with a lab coat.

0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)

Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally with a lab coat.

Time 5 (5%) – 5 (5%)

The video does not exceed the 8-minute time limit.

0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)

The video exceeds the 8-minute time limit. (Note: Information presented after the 8 minutes will not be evaluated for grade inclusion.)

Objectives for the Presentation 5 (5%) – 5 (5%)

3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom’s verbs are used. Objectives are targeted and clear.

4 (4%) – 4 (4%)

3–4 objectives provided and written in terms of what the audience will know or be able to do after viewing. Appropriate Bloom’s verbs are used.

3.5 (3.5%) – 3.5 (3.5%)

At least 3 objectives provided and written in terms of what the audience will know or be able to do after viewing, but are somewhat vague or unclear. Appropriate Bloom’s verbs may be missing.

0 (0%) – 3 (3%)

Fewer than 3 objectives provided. Objectives for the presentation are vague, unclear, or missing.

Discuss subjective data:

 

• Chief complaint

 

 

• History of present illness (HPI)

 

 

• Medications

 

 

• Psychotherapy or previous psychiatric diagnosis

 

 

• Pertinent histories and/or ROS

5 (5%) – 5 (5%)

The video is a Kaltura video and accurately and concisely presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

4 (4%) – 4 (4%)

The video is not a Kaltura video but easily opened and accurately presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis.

3.5 (3.5%) – 3.5 (3.5%)

The video is not a Kaltura video and did not open without needing to reach the student. The 2nd attempt video presents the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis but is somewhat vague or contains minor inaccuracies.

0 (0%) – 3 (3%)

There is no video submission or video presents an incomplete, inaccurate, or unnecessarily detailed/verbose description of the patient’s subjective complaint, history of present illness, medications, psychotherapy or previous psychiatric diagnosis, and pertinent histories and/or review of systems that would inform a differential diagnosis. Or subjective documentation is missing.

Discuss objective data:

 

• 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

9 (9%) – 10 (10%)

The video accurately and concisely documents the patient’s physical exam for pertinent systems. Pertinent diagnostic tests and their results are documented, as applicable.

8 (8%) – 8 (8%)

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable.

7 (7%) – 7 (7%)

Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies.

0 (0%) – 6 (6%)

The response provides incomplete, inaccurate, or unnecessarily detailed/verbose documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

Discuss results of assessment:

 

• Results of the mental status examination

 

 

• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. 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.

18 (18%) – 20 (20%)

The video accurately documents the results of the mental status exam. Video presents at least 3 differentials in order of priority for a differential diagnosis of the patient, and a rationale for their selection.

Response justifies the primary diagnosis and how it aligns with DSM-5 criteria.

16 (16%) – 17 (17%)

The video adequately documents the results of the mental status exam.

Video presents 3 differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria.

14 (14%) – 15 (15%)

The video presents the results of the mental status exam, with some vagueness or inaccuracy.

Video presents 3 differentials for the patient and a rationale for their selection. Response somewhat vaguely justifies the primary diagnosis and how it aligns with DSM-5 criteria.

0 (0%) – 13 (13%)

The response provides an incomplete, inaccurate, or unnecessarily detailed/verbose description of the results of the mental status exam and explanation of the differential diagnoses. Or assessment documentation is missing.

Discuss treatment plan:

 

• A treatment plan for the patient that addresses psychotherapy; one health promotion activity and one patient education strategy; plan for treatment and management, including alternative therapies; pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters; and a rationale for the approaches selected.

18 (18%) – 20 (20%)

The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear and concise rationale for the treatment approaches recommended is provided.

16 (16%) – 17 (17%)

The video clearly outlines an appropriate treatment plan for the patient that addresses psychotherapy, health promotion and patient education, treatment and management, pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters. A clear rationale for the treatment approaches recommended is provided.

14 (14%) – 15 (15%)

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient and provides a rationale for the treatment approaches recommended.

0 (0%) – 13 (13%)

The response does not address the diagnosis or is missing elements of the treatment plan.

Reflect on this case. Discuss what you learned and what you might do differently.

 

Pose 3 questions or discussion prompts, based on your presentation, that your colleagues can respond to after viewing your video.

5 (5%) – 5 (5%)

Reflections are thorough, thoughtful, and demonstrate critical thinking.

Questions or prompts for colleagues are thought-provoking and will require substantive responses and critical thinking.

4 (4%) – 4 (4%)

Reflections demonstrate critical thinking. Questions or prompts for colleagues are appropriate and will require substantive responses.

3.5 (3.5%) – 3.5 (3.5%)

Reflections are somewhat general or do not demonstrate critical thinking. Questions or prompts for colleagues are somewhat general and may not require substantive responses.

0 (0%) – 3 (3%)

Reflections are incomplete, inaccurate, or missing. Questions or prompts for colleagues are general, inappropriate, or missing.

Focused SOAP Note 9 (9%) – 10 (10%)

The response clearly, accurately, and thoroughly follows the SOAP format to document the selected patient case. 2 SOAP notes are submitted one in word and one pdf/images of preceptor signature.

8 (8%) – 8 (8%)

The response accurately follows the SOAP format to document the selected patient case. Only word document SOAP note submitted, no pdf/images of preceptor signature submitted.

7 (7%) – 7 (7%)

The response follows the SOAP format to document the selected patient case, with some vagueness and inaccuracy. Only pdf/images of preceptor signature submitted, no word document SOAP note submitted.

0 (0%) – 6 (6%)

The response incompletely and inaccurately follows the SOAP format to document the selected patient case. No word document or pdf/images of preceptor signature submitted.

Presentation Style 5 (5%) – 5 (5%)

Presentation style is exceptionally clear, professional, and focused.

4 (4%) – 4 (4%)

Presentation syle is clear, professional, and focused.

3.5 (3.5%) – 3.5 (3.5%) 0 (0%) – 3 (3%)

Presentation style is unclear, unprofessional, and/or unfocused.

Discussion Facilitation 9 (9%) – 10 (10%)

Presenters effectively lead, sustain, and engage the discussion from Day 4 through Day 7.

8 (8%) – 8 (8%)

Presenters lead, sustain, and engage the discussion from Day 4 through Day 7.

7 (7%) – 7 (7%)

Presenters lead, sustain, and engage the discussion at least three out of four days between Days 4 and 7.

0 (0%) – 6 (6%)

Presenters did not sustain and engage the discussion through Day 7.

Total Points: 100

Expert Answer and Explanation

Subjective:

CC (chief complaint): “I have difficulty falling asleep, am always sad, and am easily distracted.’

HPI: The patient is a 26-year-old female who presented to the office complaining of anxiety, depression, and insomnia. The patient notes that she has been having problems with falling asleep, is easily distracted, is always sad, and has difficulties completing tasks. The patient also complains that she has trouble wanting to see people and associating with people. The patient notes that she finds comfort in isolating herself. She reports anhedonia and cried during the interview. She also reports severe anxiety. She says that her anxiety became more severe when she had that the person who raped her was released from jail. The symptoms have negatively affected her life. Her therapist pulled her out of work, and she hardly made friends with people. She rates her anxiety and depression as 8/10.

Substance Current Use: She reports no current use of illicit drugs.

Medical History: The patient has no medical problems.

  • Current Medications: She is not on any medications at the moment.
  • Allergies: She reports no allergies.
  • Reproductive Hx: No reproductive problems.

ROS:

  • GENERAL: She denies fatigue, weight loss, chills, or fever.
  • HEENT: Eyes: No yellow sclerae, visual loss, or double vision. Ears, Nose, Throat: No hearing problems, runny nose, congestion, sore throat, or sneezing.
  • SKIN: No rash or itching.
  • CARDIOVASCULAR: No chest pain, edema, chest discomfort, or palpitations.
  • RESPIRATORY: No shortness of breath.
  • GASTROINTESTINAL: No diarrhea, vomiting, abdominal blood, or pain.
  • GENITOURINARY: She reports no odd urine color, no odor of urine, or burning on urination.
  • NEUROLOGICAL: No dizziness, headache, syncope, ataxia, paralysis, numbness, or tingling in the extremities.
  • MUSCULOSKELETAL: No joint or muscle stiffness or pain.
  • HEMATOLOGIC: No anemia, HIV, bleeding, or bruising.
  • LYMPHATICS: No enlarged nodes.
  • ENDOCRINOLOGIC: No reports of health intolerance, cold, or sweating abnormities.

Objective:

Vital Signs: BP 102/90, P 67, RR 17, Ht. 5’4″, Wt. 67kgs, Temp 36.5.

Physical Exam 

  • HEENT: Noncontributory.
  • Skin: No rash or itching.
  • Cardiovascular: Regular heart rhythm and heart rate. No cracks on the chest walls. No edema.
  • Respiratory: Normal breathing sounds, no wheezing, no fluids in the lungs, crackles, and no inspiratory crackles.

Diagnostic results:

  1. Beck Anxiety Inventory (BAI): Lemos et al. (2019) noted that BAI is used to measure the severity of patients’ anxiety. The authors found that the tool’s reliability is (Cronbach’s α=0.92) in terms of internal consistency. The patient scored 37, meaning that she has severe anxiety.
  2. Beck’s Depression Inventory (BDI): BID is a screening tool used to screen for depression (García-Batista et al., 2018). The patient scored 23, meaning that she has moderate depression.

Assessment:

Mental Status Examination: 

The patient is well-dressed, and her clothing is consistent with the day’s weather. She was well-behaved during the interview. However, she was crying while answering questions. She maintained eye contact during the interview. She reports sadness and affect consistent with her mood. Her speech is intact. She denies hallucinations, delusions, suicidal thoughts, or homicidal thoughts. Her memory is intact. Through process is also intact.

Diagnostic Impression:

  1. Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41. 1)
  2. Mood disorder, ICD 10 Code: F33.2 – Major Depressive Disorder, Severe, Recurrent
  3. Insomnia Disorder DSM-5 780.52 (G47.00)

The primary diagnosis for this case is GAD. According to Price et al. (2019), GAD is associated with extreme anxiety, which cannot be controlled easily. The anxiety must be characterized by at least three symptoms: fatigue, irritability, difficulty sleeping, impaired concentration, restlessness, and muscle pain. The patient is diagnosed with anxiety because she reports extreme anxiety because she heard that the person who raped her was recently released from jail. The second diagnosis is MDD. MDD is one of the mood disorders that affect a patient’s mood. The disease is part of the diagnosis because the patient reports sadness and anhedonia (Cherukupally et al., 2020). However, it is not the main disorder because the patient scored 23 in BDI. The last diagnosis is insomnia. Insomnia was included because the patient had sleeping problems. However, the disorder is a secondary disorder because it is caused by GAD (Price et al., 2019).

Reflections:

This case is a complex case. The patient has both GAD and MDD. Her symptoms meet the criteria for both GAD and MDD. Therefore, her treatment should consider symptoms of both disorders. If I was given the case, I would diagnose the patient with both MDD and GAD and the primary disorders. Insomnia she is experiencing is a result of the two disorders. The ethical consideration I would consider in this case is acting for the patient’s good. The treatment plan I would develop should not harm and be in the patient’s best interest.

Case Formulation and Treatment Plan:

The primary diagnosis for this case is GAD. However, the patient also has MDD. MDD affects her mood and makes it hard for her to connect with people. The patient is currently attending a therapy session twice a week. She was asked to stop working during treatment by her therapist. The wants to start Zoloft 50 MG Oral Tablet 1 tablet daily, traZODone HCl 50 MG Oral Tablet one tablet daily, and RTC in two weeks. Chowdhuri et al. (2019) noted that Zoloft is an effective medication for depression and anxiety. Trazodone HCl is an effective medication for anxiety. Erickson et al. (2021) noted that trazodone relieves anxiety.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (DSM-5®). American Psychiatric Pub.

Cherukupally, K. R., Kodjo, K., Ogunsakin, O., Olayinka, O., & Fouron, P. (2020). Comorbid Depressive and Anxiety Symptoms in a Patient with Myasthenia Gravis. Case Reports in Psychiatry, 2020. https://doi.org/10.1155/2020/8967818

Chowdhuri, S., McCrea, S., Fushman, D. D., & Taylor, C. O. (2019). Extracting biomedical terms from postpartum depression online health communities. AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science, 2019, 592–601.

Erickson, A., Harbin, K., MacPherson, J., Rundle, K., & Overall, K. L. (2021). A review of pre-appointment medications to reduce fear and anxiety in dogs and cats at veterinary visits. The Canadian Veterinary Journal = La Revue Veterinaire Canadienne, 62(9), 952–960.

García-Batista, Z. E., Guerra-Peña, K., Cano-Vindel, A., Herrera-Martínez, S. X., & Medrano, L. A. (2018). Validity and reliability of the Beck Depression Inventory (BDI-II) in general and hospital population of Dominican Republic. PloS One, 13(6), e0199750.

Lemos, M. F., Lemos-Neto, S. V., Barrucand, L., Verçosa, N., & Tibirica, E. (2019). Preoperative education reduces preoperative anxiety in cancer patients undergoing surgery: Usefulness of the self-reported Beck anxiety inventory. Revista Brasileira de Anestesiologia, 69, 1-6. https://doi.org/10.1016/j.bjane.2018.07.004

Price, M., Legrand, A. C., Brier, Z., & Hébert-Dufresne, L. (2019). The symptoms at the center: Examining the comorbidity of posttraumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Journal of Psychiatric Research, 109, 52–58. https://doi.org/10.1016/j.jpsychires.2018.11.016

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