Assignment 2: Focused SOAP Note and Patient Case Presentation
- 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.
- 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.
Assignment 2: Focused SOAP Note and Patient Case Presentation To Prepare Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template Week (enter week #): (Enter assignment title) Student Name College of Nursing-PMHNP, Walden University NRNP 6665: PMHNP Care Across the Lifespan I Faculty Name Assignment Due Date Subjective: CC (chief complaint): HPI: Substance Current Use: Medical History: Current Medications: Allergies: Reproductive Hx: ROS: GENERAL: HEENT: SKIN: CARDIOVASCULAR: RESPIRATORY: GASTROINTESTINAL: GENITOURINARY: NEUROLOGICAL: MUSCULOSKELETAL: HEMATOLOGIC: LYMPHATICS: ENDOCRINOLOGIC: Objective: Diagnostic results: Assessment: Mental Status Examination: Diagnostic Impression: Reflections: Case Formulation and Treatment Plan: References © 2021 Walden University Page 3 of 3
Assignment 2: Focused SOAP Note and Patient Case Presentation To Prepare Review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded
This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/ Week 9: Focused SOAP Note and Comprehensive Assessment Holly Bowling College of Nursing-PMHNP, Walden University PRAC 6665: PMHNP Care Across the Lifespan I Practicum Latanya Battle-Wherry May 3, 2021 This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/Subjective: CC : Parents are seeking a second opinion for a possible misdiagnosis of ADHD and OCD, and a possible diagnosis of Autism. HPI: This is a 10-year-old Caucasian male who presents with his parents for being easily distracted, inability to wait his turn in lines, very fidgety, and always wanting to get out of his seat. The parents explain that he has had these compulsive and rigid behaviors since a young child, but they have become more worse as he has gotten older. He likes the same routine always, and does not like changes, and gets very upset if his mother makes any change in his daily routine. Specific changes include, if his mother takes a different route to school, or if rules are not followed exactly as they should be at school. His parents endorse that instead of playing with toys, he takes them apart. He does not interact well with other kids at school and does not know how to act when they try to talk or play with him. He has issues with sharing or taking turns. They endorse that during his first year of life he would not smile at them or babble, or even make eye contact with them, and had limited expressions. They stated that he was different from his siblings in the fact that he was harder to read because he did not express his emotions like the other two children. He was not interested in normal games and activities like his siblings, such as dress-up or imagination games. They said he has never been one to seek praise when he has an accomplishment. And he shows no empathy or effort to comfort his friends when they would get hurt or seem upset. At the age of five, they said he became more aggressive toward people if they would try to invade his space, and he has not interested in engaging in play, or conversation, or even games with kids his age, and that he usually stays to himself. His parents endorse his behavioral symptoms of aggression and agitation have become worse as he gets older, and he frequently gets suspended. His behaviors seem to be worse when he is in a loud environment, such as the playground or places where there are a lot of people. He has been noted to have an average IQ with superior to gifted abilities in information and block design. He greets people by asking them questions about cars and provides them with detailed information about specific makes and models, however, he has issues responding to people or making eye contact. Because of his high cognitive abilities and behavior issues, he was placed in an alternative program , however, he is not succeeding because he is being treated as if he has ADHD with disruptive behaviors. Substance Current Use: Denies. No family history. No abuse or neglect. Medical History: One neurologist noted clumsiness, difficulties holding a pencil correctly, and poor handwriting. Otherwise, no medical history. Current Medications : He has been trialed on Clonidine, Stimulants, and Paroxetine but they all had unpleasant side effects and none of them worked for him. Denies taking any current medications. This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/Allergies : Denies Reproductive Hx : Carried full term without any issues; met all developmental milestones ROS : GENERAL: Well-appearing, alert, withdrawn, non-interactive; no changes in weight; no fevers, chills, weakness, or fatigue HEENT: No hearing changes, ear pain, or nasal congestion SKIN: No lesions, pruritis, or hair changes CARDIOVASCULAR: No CP, SOB, or cough RESPIRATORY: No cough, sputum, wheezing, dyspnea, or smoke exposure GASTROINTESTINAL: No N/V/D, no changes in weight or appetite GENITOURINARY: No pain with urination, blood in urine, or changes in color NEUROLOGICAL: No numbness, weakness, or paresthesia PSYCHOLOGICAL: No eating concerns, delusions, rumination, SI/HI/AH/VH, or personality changes. Provides minimal eye contact or information when asking questions. MUSCULOSKELETAL: No muscle or joint pain, or stiffness HEMATOLOGIC: No bruising, bleeding, or transfusion history LYMPHATICS: No enlarged lymph nodes ENDOCRINOLOGIC: No increased sweating or heat or cold intolerance; no polyuria/polydipsia Objective: The client presents with a restricted mood; however, no other physical abnormalities were noted that relate to the client’s diagnosis. Diagnostic results : There is no single test that is diagnostic of autism. To have a diagnosis of Autism, an individual must satisfy the diagnostic criteria outlined in the DSM-5. The basic triad of impairments underlying Autism has included impairment of social interaction, impairment of communication, and restricted repetitive and stereotyped patterns of behavior (Association For Science in Autism Treatment (ASAT), 2020). This client’s history of marked social communication deficits, isolation, and restricted interests is consistent with the DSM-5 diagnosis of ASD. Additional standardized instruments that are often utilized for ASD include The Childhood Autism Rating Scale (CARS), The Gilliam Autism Rating Scale (GARS), or a combination of the Autism Diagnostic Interview-Revised (ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) (ASAT, 2020). A medical evaluation is recommended to This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/determine if there is a specific, diagnosable medical condition that is associated with autistic behaviors or whether there are medical conditions commonly associated with autism, such as seizure disorder, that require further evaluation and treatment. An audiological evaluation is always an important aspect of the comprehensive assessment (ASAT, 2020). According to the information provided by his parents, there is no other diagnosable medical condition that would be associated with his manifestations. Assessment: Mental Status Examination : This is a 10-year-old Caucasian male who looks age stated , appearance is neat and clean, and dressed appropriately. He is restless and fidgety during the interview. He did not answer questions directed toward him but instead would ask the interviewer about specific cars. Upon response to the client’s question, he then proceeded to list vehicle designs and comment the interviewer on her voice. Talking about cars, seemed to open the client up, and his tone became more expressive, and eye contact more engaged. He knew he did not make friends but was unsure of why. Unable to assess mood accurately due to limited facial expressions and inability to describe his feelings. He denies SI, HI, hearing or seeing things, or any kind of hallucinations. Denies sleep or issues with appetite. Diagnostic Impression: Autism Spectrum Disorder (ASD) (F84.0)- To diagnose ASD, all of the five criteria must be met including social communication deficits, fixated interests, and repetitive behaviors consisting of four items including stereotyped or repetitive motor movements, insistence on sameness, highly restricted, fixated interests that are abnormal in intensity or focus, and hyper or hypo reactivity to sensory input or unusual interests in sensory aspects of the environment, of which at least two must be met to satisfy this criterion; symptoms existing in early childhood; symptoms impairing functioning; and impairments are not better explained by intellectual disability or global developmental delay (APA, 2013). Based on the evidence of his persistent difficulties in social interaction and communication, as well as the restricted patterns of behavior that have been presenting from an early age, including his consistent daily routines and inability to change them, his lack of eye contact and smiling, his non-verbal behaviors, his inability to form relationships, his fixation on cars, the disturbances cause clinically significant impairment in social functioning, as evidenced by his pronounced difficulties in social interaction, absence of friendships, aggression, oppositional behaviors, and inflexibility and/or rage in response to changes in routines, and the fact that he does not have a history of clinically significant delay in language development, cognitive development, or acquisition of other adaptive behaviors, provides enough criteria and makes the diagnosis of ASD justifiable. ADHD Combined (F90.2)- According to the DSM-5, a diagnosis of ADHD is defined as the presence of six or more specific symptoms occurring for at least six months of either inattention, hyperactivity, or both (APA, 2013). Specific issues that can be seen with ADHD include poor performance in school, behavioral problems, difficulty expressing feelings or building relationships, and the inability to think correctly (Krull, 2019). This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/Hyperactivity, impulsiveness, inattention are not typical core features of ASD, however, they are common in this clinical presentation and are justifiable manifestations for a second diagnosis of ADHD. Social Communication Disorder (SCD) (F80.89)- Shows deficits in social communication but also demonstrates an absence of interest in social communication and social-emotional reciprocity, impairment of the ability to change communication to match context or the needs of the listener, difficulties following rules during a conversation, and difficulties making inferences ( Mandy, Wang, Lee, & Skuse, 2017). ). The differentiation between SCD and ASD is that ASD presents with highly restricted interests, insistence on sameness, and inflexible adherence to routines. Therefore, since the client is shown to have a history of presenting manifestations, a diagnosis of SCD can be ruled out. Obsessive-Compulsive Disorder (OCD)- OCD is a common, chronic, and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts and/or behaviors that he or she feels the urge to repeat over and over (NIMH, 2019). Diagnostic criteria include the presence of obsessions, compulsions, or both, and they are time-consuming or cause significant impairment in social functioning. They must not be attributed to the effects of another substance or better explained by another mental disorder (APA, 2013). The clinical picture is not consistent with that OCD, although his preoccupation with cars may be considered obsessive, it is not an obsessional concern. Children with OCD typically describe the intrusion of unwanted thoughts that are difficult to dislodge, however, this client likes to think and talk about cars all the time. His reoccurring thoughts and insistence on routines are better justified as ASD than OCD. Reflections: The main thing I learned while doing this case study was that there are many symptoms of ASD that manifest as other disorders such as OCD, ADHD, social communication disorder, as well as many others. Therefore, it is important to get as much information as possible before making a definitive diagnosis to come up with the best treatment plan specific for each patient. Symptoms of ASD usually manifest at an early age, however many parents don’t realize there is an issue until sometimes years later. Therefore, it is important to educate parents on symptoms associated with ASD and to start early interventions to have the best possible outcome. Overall, there is not much I would change about the way this client was treated. The only thing I might change or do different would be to have the parents and teachers fill out the ABC before seeing the client, that way we would have had a better idea of how serious his symptoms were, and could have started medication treatment right away if needed. Case Formulation and Treatment Plan : This is a 10-year-old Caucasian boy, who lives with his parents, an older sister, and a younger brother, and presents with his parents who are seeking a second opinion about their sons’ diagnoses of attention-deficit/ hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). They endorse odd behaviors since 12 months of age, such as not making eye contact and absence of appropriate nonverbal behaviors. Upon doing their own investigation, they have some new insight regarding possible causes for their son’s behavioral issues. He has unusual manifestations of, ritualistic behaviors, lack of interest in play, or other children, lack of participation in social groups, he doesn’t share or take turns, and This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/insensitivity to social patterns. The main focus of treatment for this client will be educational and behavioral therapy. Medication options are generally used to target behaviors, such as irritability, hyperactivity, anxiety, and repetitive behavior, rather than the social disability of ASD. He needs to be placed in a special education class that is least restrictive and in an appropriate setting (Autism Society, 2020). The focus of his class should be on his social disability, which is central to ASD. He needs something that will promote social skills, such as communication techniques, greeting people, initiating games, and joint attention, as his social disability is interfering with his overall academic success (Sadock, Sadock, & Ruiz, 2015). This client will benefit from behavioral therapy that focuses on specific maladaptive behavior, such as aggression, as well as specific skills-building, such as his language or everyday living skills. Behavioral therapy has been shown to reduce aggression and self-injurious behaviors and is considered the gold standard of treatment for behavioral problems related to ASD (Maneeton, Maneeton, Putthisri, Woottiluk, Narkpongphun, & Srisurapanont, 2018). Parent behavioral training will also be beneficial in helping the parents to improve his behavior in the home and the community. We will have his parents and teachers fill out an Abberent Behavior Checklist (ABC) which will help in identifying target symptoms. We will hold off on medication treatment until he can establish an individualized education program (IEP), hopefully, in a timely manner ( Schmidt, Huete, Fodstad, Chin, & Kurtz, 2013). However, if this process is prolonged, then it will be important to consider medication management to target his hyperactivity, such as Methylphenidate, as it has been shown to be beneficial in targeting hyperactivity in those diagnosed with ASD ( Sturman, Deckx, & Van Driel, 2017). Risperidone is another drug that is FDA approved for the use of irritability and has been proven to be effective in reducing irritability and hyperactivity in those diagnosed with ASD (Maneeton et al., 2018). Depending on the outcome of the ABC checklist and the timely manner of the IEP, Methylphenidate, and Risperidone will both be beneficial options for medication management. Self-management techniques will also be beneficial for this client as they work by targeting a specific behavior and teach the client to identify an occurrence of the behavior while recording, evaluating, and then self-reinforcing. Self-management can help with controlling his excessive motor activity, help him learn to follow directions, reduce his rituals, as well as learning more appropriate social approaches (Schulze, 2016). The client is to follow up in one month and depending on the ABC checklist, IEP, and client symptoms, we will decide whether or not to add in medication treatment. Many individuals with ASD have issues with sleeping, as well as a higher incidence of gastrointestinal issues. It is important to teach them good sleep hygiene, such as providing a good sleep environment and a normal bedtime routine, as well as appropriate foods and medications to help with gastrointestinal symptoms, such as belching, constipation, and diarrhea (Sadock et al., 2015). Some alternative approaches that might be utilized include music therapy to promote communication and expression, and yoga to promote attention and decrease activity level (Sadock et al., 2015). This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Association For Science In Autism Treatment (ASAT). (2020). Autism diagnosis. Retrieved from https://asatonline.org/for-parents/diagnosis/?gclid=CjwKCAjwg4- EBhBwEiwAzYAlsgdjGtBMlSGBfd57LWXw07bB7uLWRK7-Jbib6LOMQx- Heb9GXoj7xhoCr-oQAvD_BwE Autism Society. (2020). Academic success. Retrieved from https://www.autism- society.org/living-with-autism/academic-success/ Krull, K. (2019). Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis. Retrieved from https://www.uptodate.com/contents/attention- deficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis Maneeton, N., Maneeton, B., Putthisri, S., Woottiluk, P., Narkpongphun, A., & Srisurapanont, M. (2018). Risperidone for children and adolescents with autism spectrum disorder: a This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/systematic review. Neuropsychiatric disease and treatment , 14 , 1811–1820. https://doi.org/10.2147/NDT.S151802 National Institute of Mental Health. (2020). Obsessive-Compulsive Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. Schmidt, J. D., Huete, J. M., Fodstad, J. C., Chin, M. D., & Kurtz, P. F. (2013). An evaluation of the Aberrant Behavior Checklist for children under age 5. Research in developmental disabilities , 34 (4), 1190–1197. https://doi.org/10.1016/j.ridd.2013.01.002 Schulze, M. A. (2016). Self-Management Strategies to Support Students With ASD. Teaching Exceptional Children , 48 (5), 225–231. https://doi- org.ezp.waldenulibrary.org/10.1177/0040059916640759 Stahl, S. M. (2014). The prescriber’s guide (5 th ed.). New York, NY: Cambridge University Press. This study source was downloaded by 100000794395091 from CourseHero.com on 10-26-2022 23:09:25 GMT -05:00 https://www.coursehero.com/file/94345132/WK9Assgn2bowlinghPRAC6665docx/ Powered by TCPDF (www.tcpdf.org)Sturman, N., Deckx, L., & van Driel, M. L. (2017). Methylphenidate for children and adolescents with autism spectrum disorder. The Cochrane database of systematic reviews , 11 (11), CD011144. https://doi.org/10.1002/14651858.CD011144.pub2 Mandy, W., Wang, A., Lee, I., & Skuse, D. (2017). Evaluating social (pragmatic) communication disorder. Journal of Child Psychology and Psychiatry, and Allied Disciplines , 58 (10), 1166–1175. https://doi-org.ezp.waldenulibrary.org/10.1111/jcpp.12785