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
Substance Abuse Disorder
CC: “temper tantrums in the home”
HPI: RM is an 8-year-old Caucasian female brought to the clinic with a CC of “temper tantrums in the home.” The patient’s parents note that the behavior often begins when they try to instruct her on what she is doing. The parents indicate the problem starts when they want to transition her from playing with her toys to coming to the dinner table, or during bedtime, bath time, and when getting dressed in the morning. During the bouts, the patient becomes enraged and augmentative, refusing to follow rules or follow instructions and at times defiantly does thig to annoy the parents.
Substance Current Use and History: The patient and the parents deny a history of substance use or abuse. The patient denies having ever taken alcohol or any other illicit substances.
Family Psychiatric/Substance Use History: The patient’s parents deny any use of substances, alcohol, or cigarettes. Mother was diagnosed with acute anxiety, which is well managed.
Psychosocial History: The patient lives with his parents. The parents state that she has no history of mental illness. They also indicate the patient has not been performing well in school and usually engages in fights with other kids which has made her teachers worried. The patient enjoys playing with her toys and watching cartoons during her free time.
Medical History: The patient is healthy with no diagnosis of any physical health condition
- Current Medications: Not under any medications
- Allergies: not allergic to food, medication, or environmental substances.
- Reproductive Hx: No abnormalities stated
- GENERAL: Negative for fatigue, fever, or chills.
- HEENT: No abnormalities stated
- SKIN: No rashes, wounds, or itchiness stated
- CARDIOVASCULAR: Denies having any chest pain or discomfort
- RESPIRATORY: No coughs or difficulty in breathing
- GASTROINTESTINAL: Negative affirmation for any GI abnormalities and pain
- GENITOURINARY: Negative for GU symptoms
- NEUROLOGICAL: No headaches or neurological pain
- MUSCULOSKELETAL: No MS issues stated.
- HEMATOLOGIC: Negative for hematologic issues.
- LYMPHATICS: Negative lymphadenopathy.
- ENDOCRINOLOGIC: Negative for any endocrine symptoms.
Physical exam: GENERAL:
Vital Signs: T- 97.2 P- 62 R 14 BP 95/60 Ht. 4’4, Wt. 58lbs, R 14, BP 95/60
- Head: No deformities or scars noted
- Eyes: conjunctiva clear, White scleral, visual acuity 20/20.
- Ears: Hearing intact.
- Nose: Nasal mucosa moist and pink, nares are patent.
- Throat: No swelling or pain when swallowing.
- Skin: N/A
- Cardiovascular: No murmurs. Normal HR and BP.
- Respiratory: Lungs clear to auscultation
- Gastrointestinal: N/A
- Neurological: Cranial nerves intact.
- Musculoskeletal: N/A
Mental Status Examination: The patient is an 8-years-old Caucasian female who appears appropriately developed for her age. She talks with a clear, logical, and coherent speech. She is oriented to time, event, person, and place. She is well-groomed and properly dressed for the occasion and weather. No observable out-of-place mannerisms, tics, or gestures. She does not exhibit or indicate any signs or symptoms of paranoia, hallucination, or delusions and her attention and concertation are grossly intact. She also denies having any suicidal ideations. Her insight and judgment are appropriate for her age.
F91.3 – Oppositional defiant disorder.
F 90.9 – Attention-deficit hyperactivity disorder, unspecified type.
F34. 8 – Disruptive mood dysregulation disorder
The primary diagnosis for the presented disorder is oppositional defiant disorder (ODD). According to the DSM-V criteria, this is a disorder characterized by emotional and behavioral symptoms lasting for at least six months (APA, 2013).In addition, the patient should be experiencing angry and easily irritable moods, where the patient easily gets annoyed, loses temper, and feels resentment and anger. In addition, the patient may have augmentative and defiant behavior coupled with vindictiveness (APA, 2013).
In most cases, pharmacologic interventions are not needed for patients with ODD, unless they have another comorbid mental disorder such as ADHD (Aggarwal & Marwaha, 2020). Instead, family-based therapy is preferred in such patients. Some of the effective psychotherapeutic approaches include parental, training, family-based therapy, cognitive-behavioral therapy, and individual therapy to list a few. For this particular patient, she was started with methylphenidate (Ritalin) 10mg daily and will f/u in 2 weeks to regulate symptoms of hyperactivity. The parents were referred to a therapist for CBT and a parenting program. As part of the patient education, parents were advised to set limits by giving clear instructions and consequences in advance if the instructions are not followed. The parents were also told to embrace a system of rewarding good behavior to act as reinforcers to positive behavior (Booker et al., 2019).
In most cases, treatment for oppositional defiant disorder requires significant elements of family-based interventions. One element I would consider is trying to probe more into what works for the parents in trying to manage the patient’s temper tantrums. I would expect the interventions to show some signs of success after the first month or so. Based on the study by Ghosh et al. (2017), family-based therapy has been proven efficacious among children with ODD, showing results from one month onwards after initiating the intervention. Some of the gains from the intervention include, reduced frequency of the aggressive bouts, increased compliance to directions, and more rational actions when aggravated. Another way to ascertain whether the intervention was successful is by evaluating the parent’s mental state, whereby, in the event of successful treatment they should experience fewer poor mental health outcomes if the study by Katzmann et al. (2021) is anything to go by. Depending on how the patient responds to the intervention, I may opt to recommend some adjustments to the treatment regimen and possible further diagnosis of other likely associated disorders.
Aggarwal, A., & Marwaha, R. (2020). Oppositional Defiant Disorder. In StatPearls [Internet]. StatPearls Publishing.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (Vol 5). (2013). American psychiatric association.
Booker, J. A., Capriola-Hall, N. N., Greene, R. W., & Ollendick, T. H. (2019). The parent-child relationship and posttreatment child outcomes across two treatments for oppositional defiant disorder. Journal of Clinical Child & Adolescent Psychology.
Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: current insight. Psychology research and behavior management, 10, 353–367. https://doi.org/10.2147/PRBM.S120582
Katzmann, J., Döpfner, M., & Görtz-Dorten, A. (2018). Child-based treatment of oppositional defiant disorder: mediating effects on parental depression, anxiety, and stress. European child & adolescent psychiatry, 27(9), 1181-1192.
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