PRAC 6665 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION ESSAY

PRAC 6665 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION ESSAY

PRAC 6665 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION ESSAY

Focused SOAP Note and Patient Case Presentation

CC (chief complaint): ” I have been having constant nightmares of car crashes killing people.”

HPI: A.D. is a sixteen-year-old female patient who visited the facility accompanied by her mother with reports of undesirable symptoms. Since the burial of the patient’s sister, who died in a motor car accident, the patient has displayed various worrying symptoms such as self-destructive behaviors, irritability, trouble sleeping, trouble concentrating, and easily getting frightened. The patient also takes off sometimes whenever she hears the sounds of cars. The mother also indicates that her daughter has been experiencing nightmares of care cars crashing into each other and killing people. The patient has also increasingly shown symptoms of aggressive behaviors and anger outbursts. In addition, the patient does not want to walk close to the roads or near cars anymore, cries a lot, and prefers being alone most of the time.

ORDER A PLAGIARISM-FREE PAPER HERE ON; PRAC 6665 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION ESSAY

Past Psychiatric History:

• General Statement: The patient is coming for a psychiatric visit for the first time and has not used any medication for the current condition
• Caregivers (if applicable): The patient’s father and mother are both her caregivers
• Hospitalizations: The patient has not reported any incidences of previous hospitalizations.
• Medication trials: No medical trials
• Psychotherapy or Previous Psychiatric Diagnosis: The patient was diagnosed with depressive symptoms at the age of thirteen but has since been treated, and the patient has been free of the symptoms.

Substance Current Use and History: The patient denies any history of alcohol drinking, smoking, or use of other drugs and substances

Family Psychiatric/Substance Use History: The patient’s mother was once diagnosed with depression, but it was successfully managed. No other significant history.

Psychosocial History: A.D. is currently living with her mother while her father is working in a nearby town. The patient has a younger brother, apart from her elder sister, who recently died in a motor car accident.

Medical History:

• Current Medications: No history of current medication use

• Reproductive Hx: the patient is currently single and has no partner.
• ROS:

• GENERAL: No weight loss, fever, or body weakness.
• HEENT: No photophobia, loss of vision, hearing loss, dysphagia, sore throat, or nasal congestion.
• SKIN: No skin dryness or skin rash.
• CARDIOVASCULAR: There is no chest discomfort/pain, palpitations, or lower limb edema.
• RESPIRATORY: No wheezing, cough, or difficulty in breathing.
• GASTROINTESTINAL: no anorexia, abdominal pain, nausea, vomiting, diarrhea, constipation, or blood in the stool.
• GENITOURINARY: No reported discomfort or burning sensation on urination, no blood in urine, and no increased frequency.
• NEUROLOGICAL: No incontinence, dizziness, seizures, or headaches
• MUSCULOSKELETAL: There is no myalgia, arthralgia, joint stiffness, or swelling.
• HEMATOLOGIC: No anemia or bleeding.
• LYMPHATICS: There are no reported enlarged lymph nodes or splenomegaly.
• ENDOCRINOLOGIC: No polyuria, polydipsia, polyphagia, intolerance to cold or heat, or increased sweating.

Physical exam:

Vital signs: Blood pressure 119/80 mmHg, Pulse rate 78, Temperature 98.1, Height 5’8, Weight 163 lbs

General:  The patient looks normal and healthy but anxious.

HEENT: The head is atraumatic, pupils’ reaction to light is normal, no eye or ear discharges, the neck is normal, no throat inflammation.

Neurological: The cranial nerves are intact. The patient is also alert and oriented.

Cardiovascular:  the S1 and S2 are both normal, and no murmurs were detected.

Musculoskeletal: There is no muscle or joint tenderness, no joint swelling, no stiffness, and no limitations in the range of motion.

          Respiratory: No chest pain noted. Normal breathing with no labored breathing noted

Gastrointestinal: no abdominal pain; the bowel sounds present

Diagnostic results: None

Assessment

A.D. is a sixteen-year-old patient who came to the facility. She is well dressed and appears well groomed too. She is also alert and well-oriented. She appropriately maintains eye contact but struggles with concentration. She has a rushed speech and is easily angered and irritable. The patient’s memory is flawed, though she displays a coherent thought process. She denies any suicidal actions, ideations, or thoughts. She denies any thoughts of self-harm or harm to others. The patient has been having a flashback of her sister’s death in the car crash.

Differential Diagnoses:

1. Post-traumatic stress disorder (PTSD): PTSD is a condition that results from experiences of traumatic events or events and can lead to various symptoms (Fekadu et al.,2019). The patient’s sister recently died in a motorcar accident, leaving the patient traumatized and crying a lot. Patients with PTSD usually display various symptoms, including re-experiences of past traumatic or distressing events, nightmares, unpleasant flashbacks, struggle with sleep, hypervigilance, and making attempts to avoid things related to the traumatic event (Bryant, 2019). The patient has displayed the majority of these symptoms, which makes this condition the most probable diagnostic.

2. Depression: Depression is one of the most common mental illness conditions and makes patients have poorer health outcomes (Tolentino & Schmidt, 2018). The patient has shown some depressive symptoms since the burial of her sister. While the patient was previously diagnosed with depression and treated, the latest symptoms are likely connected to the experience she has had of her sister dying in a car crash. The patient has particularly been having problems with her sleep. Depression is, therefore, one of the potential diagnoses since it can also coexist with PTSD (Nichter et al.,2019).

3. Social anxiety disorder: This is a condition where a patient usually avoids social situations. The patient has been displaying various symptoms, like continually wanting to be left alone and crying a lot. Such behavior has been observed since her sister was buried. However, she did not display other symptoms which could make this diagnosis a primary diagnosis.

Reflections:

It is important to carry out a comprehensive patient assessment to help in formulating appropriate care and management plan. Therefore, the mental state examination combined with the past patient history is key in getting the necessary data that can be used to help formulate an appropriate care plan. Such a care plan can be used to help the patient improve and reduce unpleasant symptoms. The patient assessment was appropriately performed to help get the necessary information from the patient and her mother. It is important to consider ethical principles when handling patients, patients with mental health challenges included. As such, in dealing with these patients, it is important to take into consideration various aspects such as autonomy, beneficence, non-maleficence, justice, privacy, and confidentiality (Ellis, 2020). It is key to ensure that any treatment and management approaches take the patient’s and their family members’ views into consideration. In addition, no harm should be done to the patient, and all other aspects should be upheld while dealing with the patient. The mother should be educated on why it is important to offer appropriate moral and social support to the patient while still experiencing the impacts of PTSD. The patient should also get enough support to start psychotherapy sessions with a major focus on improving the symptoms.

References

Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. World Psychiatry, 18(3), 259–269. https://doi.org/10.1002/wps.20656

Ellis, P. (2020). Understanding ethics for nursing students. Sage.

Fekadu, W., Mekonen, T., Belete, H., Belete, A., & Yohannes, K. (2019). Incidence of post-traumatic stress disorder after road traffic accident. Frontiers In Psychiatry, 10, 519. https://doi.org/10.3389/fpsyt.2019.00519

Hyett, M. P., & McEvoy, P. M. (2018). Social anxiety disorder: looking back and moving forward. Psychological Medicine, 48(12), 1937-1944. https://doi.org/10.1017/S0033291717003816

Nichter, B., Norman, S., Haller, M., & Pietrzak, R. H. (2019). Psychological burden of PTSD, depression, and their comorbidity in the US veteran population: Suicidality, functioning, and service utilization. Journal of Affective Disorders, 256, 633-640. https://doi.org/10.1016/j.jad.2019.06.072

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: implications for clinical practice. Frontiers In Psychiatry, 9, 450. https://doi.org/10.3389/fpsyt.2018.00450

BUY A CUSTOM-PAPER HERE ON; PRAC 6665 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION ESSAY

FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1

Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.

RESOURCES

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE

• 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 patient of any age (either a child or an adult) that you examined during the last 3 weeks.
• 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, 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 the completed assignment signed by your Preceptor.
  • You must submit your SOAP note using Turnitin. 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.

THE ASSIGNMENT

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 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.

BY DAY 7 OF WEEK 3

Submit your Video and Focused SOAP Note Assignment. You must submit two files for the note, including a Word document and scanned pdf/images of completed assignment signed by your Preceptor.

SUBMISSION INFORMATION – PART 1: VIDEO SUBMISSION

To submit your video response entry:

1. Click on Start Assignment near the top of the page.
2. Next, click Text Entry and then click the Embed Kaltura Media button.
3. Select your recorded video under My Media.
4. Check the box for the End-User License Agreement and select Submit Assignment for review.

SUBMISSION INFORMATION – PART 2: FOCUSED SOAP NOTE SUBMISSION

To submit Part 2 of this Assignment, click on the following link:

• Week 3 Assignment 2, Part 2

BUY A CUSTOM-PAPER HERE ON; PRAC 6665 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION ESSAY

Rubric

PRAC_6665_Week3_Assignment2_Pt1_Rubric

PRAC_6665_Week3_Assignment2_Pt1_Rubric

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomePhoto ID display and professional attire	5 to >0.0 ptsExcellent Photo ID is displayed. The student is dressed professionally. 0 ptsFair 0 ptsGood 0 ptsPoor Photo ID is not displayed. Student must remedy this before grade is posted. The student is not dressed professionally.	5 pts
This criterion is linked to a Learning OutcomeTime	5 to >0.0 ptsExcellent The video does not exceed the 8-minute time limit. 0 ptsFair 0 ptsGood 0 ptsPoor The video exceeds the 8-minute time limit. (Note: Information presented after 8 minutes will not be evaluated for grade inclusion.)	5 pts
This criterion is linked to a Learning OutcomeDiscuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS	10 to >8.0 ptsExcellent The video 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. 8 to >7.0 ptsGood The video 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. 7 to >6.0 ptsFair The 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. 6 to >0 ptsPoor The 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.	10 pts
This criterion is linked to a Learning OutcomeDiscuss 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	10 to >8.0 ptsExcellent 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 to >7.0 ptsGood The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are documented, as applicable. 7 to >6.0 ptsFair Documentation of the patient’s physical exam is somewhat vague or contains minor inaccuracies. Diagnostic tests and their results are documented but contain inaccuracies. 6 to >0 ptsPoor 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.	10 pts
This criterion is linked to a Learning OutcomeDiscuss 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.	20 to >17.0 ptsExcellent The video accurately documents the results of the mental status exam. Video presents at least three 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. 17 to >15.0 ptsGood The video adequately documents the results of the mental status exam. Video presents three differentials for the patient and a rationale for their selection. Response adequately justifies the primary diagnosis and how it aligns with DSM-5 criteria. 15 to >13.0 ptsFair The video presents the results of the mental status exam, with some vagueness or inaccuracy. Video presents three 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. 13 to >0 ptsPoor 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.	20 pts
This criterion is linked to a Learning OutcomeDiscuss treatment Plan:• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, 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.	20 to >17.0 ptsExcellent The video clearly and concisely outlines an evidence-based treatment plan for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by valid research. … Discussion includes a clear and concise follow-up plan and parameters…. The discussion includes a clear and concise referral plan. … The paper discussion contains all 3 elements from the assignment directions including a discussion demonstrating critical thinking of the case related to the HealthyPeople 2030 social health determinates. Clearly and concisely relates discussion to the psychiatric and mental health field. 17 to >15.0 ptsGood The video clearly outlines an appropriate treatment plan without evidence-based discussion for the patient that addresses FDA-approved psychopharmacologic agents and includes alternative treatments and rationale supported by vague or questionable research. … Discussion includes a clear follow-up plan and parameters…. The discussion includes a clear referral plan…. The paper discussion contains 2 of the elements from the assignment directions with one being a basic discussion of the case related to the HealthyPeople 2030 social health determinates. Clearly relates discussion to the psychiatric and mental health field. 15 to >13.0 ptsFair The response somewhat vaguely or inaccurately outlines a treatment plan for the patient that addresses psychopharmacologic agents without discussion of FDA approval and includes vague or inaccurate alternative treatments with little rationale discussed. … The discussion is somewhat vague or inaccurate regarding the follow-up plan and parameters…. The discussion is somewhat vague or inaccurate regarding a referral plan. … The paper discussion contains 1 of the required elements from the assignment directions which is the HealthyPeople 2030 social health determinates…. Somewhat vaguely or inaccurately relates discussion to the psychiatric and mental health field. 13 to >0 ptsPoor The response does not address the treatment plan or the treatment plan is not appropriate for the assessment and the diagnosis. There is no mention of FDA approval for treatment choices or no research supported discussion. Alternative treatment discussion is missing. … Rationales for treatments are missing. … There is no discussion for follow-up and parameters. … There is no discussion of a referral plan. … The paper discussion is missing discussion relating to the psychiatric and mental health field or relates discussion to another specialty realm including medical co-morbidity illnesses.	20 pts
This criterion is linked to a Learning OutcomeReflect on this case. Discuss what you learned and what you might do differently.	5 to >4.0 ptsExcellent Reflections are thorough, thoughtful, and demonstrate critical thinking. 4 to >3.5 ptsGood Reflections demonstrate critical thinking. 3.5 to >3.0 ptsFair Reflections are somewhat general or do not demonstrate critical thinking. 3 to >0 ptsPoor Reflections are incomplete, inaccurate, or missing.	5 pts
This criterion is linked to a Learning OutcomePresentation style	5 to >4.0 ptsExcellent Presentation style is exceptionally clear, professional, and focused. 4 to >3.5 ptsGood Presentation style is clear, professional, and focused. 3.5 to >3.0 ptsFair Presentation style is mostly clear, professional, and focused 3 to >0 ptsPoor Presentation style is unclear, unprofessional, and/or unfocused.	5 pts
Total Points: 80