Assignment 2: Focused SOAP Note And Patient Case Presentation

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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.

To Prepare

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? Assignment 2: Focused SOAP Note And Patient Case Presentation
  • 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: 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 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.

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Patient is 44-year-old African American female seen in the clinic with consent for chief complaint of “PTSD” or depression. She reports her little brother died in 2019 and her mother died in 2020. She says she briefly sought a mental health therapist in the past but was unable to connect with the therapists. She reports her family of mental illness is not confirmed but she believes her mother had depression and OCD. She was raised primarily by her mother. She reports a good relationship with her biological father who has been very active in her life. She says her 30-year-old-daughter has ADHD. She reports she was sexually abused by her stepfather from the ages of 6-12 years old and her mother physically abused her. She became pregnant at 14 and was able to earn her GED. Patient reported very poor appetite. She is sleeping only four hours per night and sometimes not at all. She reports she cannot think or focus on her job and is fearful of losing her job. She reports I feel so bad “I don’t even want to put clothes on”. She says she is not actively suicidal but she “Thinks about how it would be if I weren’t here. I don’t have a plan or anything”. She smokes marijuana “All the time” and is increasing her alcohol intake. Provider prescribed escitalopram 5mg every morning for her depression and will increase when appropriate. Hydroxyzine 25 mg three times a day as needed for her anxiety. Patient was educated on abstaining from smoking marijuana and consuming alcohol. Instruct patient in the use and side effects of escitalopram and hydroxyzine. Patient to call 911 for thoughts of suicide and homicide ideation. Assignment 2: Focused SOAP Note And Patient Case Presentation

PHQ score 21/27.

Diagnosis of Severe Depression

Vital Sign: T-98.6, R-20, P-82, B/P-130/78, Oxygen sat 100% R/A, Wt-170lbs

 

 

 

Plan: in 90 days patient will have decreased symptoms of depression.

Provider educated patient to abstain from smoking marijuana and consumption of alcohol while taking Escitalopram and hydroxyzine as they will affect effectiveness of the medications. Patient verbalized understanding.

Provider educated patient in the use and side effects of escitalopram and hydroxyzine. Instructed patient that feelings of abdominal pain, nausea and heavy headedness will pass and to continue taking medication

Provider will instruct patient to call 911 for thoughts of suicide and homicide ideation.

Follow-up visit in 2 weeks. Assignment 2: Focused SOAP Note And Patient Case Presentation

INSRUCTION

 

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.

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To Prepare

  • 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.
    Please Note:

    • 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. Assignment 2: Focused SOAP Note And Patient Case Presentation
  • 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.

The Assignment

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).
  • 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?  Assignment 2: Focused SOAP Note And Patient Case Presentation
    • 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: 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 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. Assignment 2: Focused SOAP Note And Patient Case Presentation