PRAC 6656 WEEK 7 Focused SOAP Note and Patient Case Presentation, Part 1 Paper

PRAC 6656 WEEK 7 Focused SOAP Note and Patient Case Presentation, Part 1 Paper

PRAC 6656 WEEK 7 Focused SOAP Note and Patient Case Presentation, Part 1 Paper

CC (chief complaint): ” I am tired of  nightmares of people dying in car crashes.”

HPI: S.R. is a Twenty-year-old female patient who came to the facility accompanied by an older sister with reports that her sister has not been feeling well due to horrible nightmares. The patient has been experiencing the symptoms since their brother died in a car accident some time back. The patient reports various symptoms, such as getting frightened easily, trouble concentrating, having trouble falling asleep and easily getting distracted from sleep,  and involvement in self-destructive behaviors. In some instances, the patient takes off upon hearing the sound of cars and has been having frequent nightmares of people dying in car crashes. In addition, the patient has also displayed various symptoms, such as anger outbursts and aggressive behaviors. The patient also prefers being alone and walking far from the road.

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Past Psychiatric History:

• General Statement: The patient visited a psychiatric facility for the first time. She has not used any medication since she started experiencing the symptoms. Caregivers (if applicable): The patient lives with their mother and older sister, who are her caregivers.
• Hospitalizations: There are no records of previous hospitalizations.
• Medication trials: No records of medical trials
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has no previous psychiatric diagnosis or psychotherapy.

Substance Current Use and History: The patient has no history of smoking, alcohol drinking, or the use of other illicit substances.   

Family Psychiatric/Substance Use History: The patient’s father had bipolar disorder shortly before passing on, while her mother had once been treated for anxiety disorder.  

Psychosocial History: S.R. is currently living in an apartment with her mother and an elder sister. Her younger brother was recently killed in a motorcar accident. The father also died some years back after a long struggle with diabetes but also had bipolar disorder.

Medical History:

• Current Medications: No history of current medication use

• Reproductive Hx: The patient is single with no partner. She, however, plans to get into a relationship when she turns twenty.
• 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 110/80 mmHg, Pulse rate 80, Temperature 97.0, Height 5’4, Weight 153 lbs

General:  The patient looks healthy and well-built. However, she looks bothered by her current symptoms.

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

 S.R. is a twenty-year-old patient who visited the facility accompanied by her elder sister. She is appropriately dressed and well-groomed. The patient is also alert and oriented to time and space. She establishes and maintains eye contact. However, she struggles to concentrate as she displays a short concentration span. The patient’s speech is rushed, and she is quickly irritable and angered. The patient has a coherent thought process but a flawed memory. S.R. denies suicidal thoughts, ideations, or actions though she admits being saddened by the death of her brother. The patient also denies any thoughts of self-harm or harming others.

Diagnostic Impression

1. Post-traumatic stress disorder (PTSD): This is a condition that a patient may experience following experiences with traumatic events. A patient with this condition may experience various symptoms such as avoidance of objects connected to the traumatic event, hypervigilance, complications with sleep, flashback about the traumatic event, trouble concentrating, and nightmares (Bryant et al.,2019). It is important to note that the patient’s brother recently died in a car crash; hence the symptoms can be associated with this event. The patient also showed many of these symptoms hence making this a primary diagnosis.

3. Depression: Depression is known to cause unpleasant symptoms and may need psychotherapy or medication approaches for treatment and management (Shorey et al.,2022). The patient has shown several symptoms associated with depression since the death of her brother. The patient has shown problems falling asleep and being distracted easily from sleep; depression is a possibility. Depression is also known to coexist with PTSD.
4. Social anxiety disorder: This is another potential condition. This condition is majorly characterized by individuals trying to avoid social situations (Koyuncu et al.,2019). The patient has recently shown behaviors of wanting to be alone and walking far away from the road where there are no care or people. However, the patient did not additionally show symptoms which could make this a primary diagnosis.

Reflections:

I agree with the preceptor’s assessment and diagnostic impression since the assessment was comprehensively performed, and the symptoms point to the proposed diagnoses, especially the primary diagnosis. One of the things I learned from this case is the importance of accomplishing a comprehensive patient assessment for an adequate care plan.  As such, examining the patient’s past psychiatric history, psychosocial history, and mental state examination are all key to an appropriate care management plan. Handling patients with mental health challenges requires that a practitioner upholds various ethical principles such as confidentiality, privacy, justice, non-maleficence, beneficence, and autonomy (Elis, 2021). The patient needs to be educated on the need to follow the medication and treatment plan, while the family members should be informed to offer appropriate social and moral support.

Case Formulation and Treatment Plan

The patient has sufficient symptoms to help in arriving at the stated diagnoses. Therefore, there is no need for further diagnostic studies. The patient should be referred to a psychotherapist to start sessions to help relieve the symptoms. Therefore, the conditions should be treated and managed as follows.

For PTSD, the patient should start using Zoloft, 25 mg daily, for six weeks (McFadden  & Hooker, 2020). The patient should expect various side effects such as trouble sleeping, stomach upset, diarrhea, increased sweating, loss of appetite, dry mouth, drowsiness, dizziness, and nausea. The patient should also inform the practitioner if she gets pregnant as the medication can lead to increased chances of birth defects such as heart defects. The patient can integrate this approach with psychotherapy sessions.

For depression, the patient can use 20 mg per day of Fluoxetine (García-García et al.,2022). However, various side effects are expected, including; fainting, dizziness, shortness of breath, irregular heartbeat, diarrhea, vomiting, nausea, loss of coordination, hallucination, muscle stiffness, shivering, confusion, sweating, fever, and agitation. The mediation has no risk to the pregnancy.

For social anxiety disorder, the patient can start using paroxetine, 20 mg per day. This medication has been shown to treat social anxiety disorder. However, the patient may experience various side effects. Some of the side effects include abnormal bleeding, diarrhea, vomiting, nausea, hallucination, irregular heartbeat, confusion, and agitation (Li et al.,2020). The patient should stop the medications in case the symptoms become more intense.

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

McFadden, S. L., & Hooker, B. L. (2020). Comparing perika St. John’s wort and sertraline for treatment of post-traumatic stress disorder in mice. Journal of Dietary Supplements, 17(3), 300–308. https://doi.org/10.1080/19390211.2019.1572040

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

García-García, M. L., Tovilla-Zárate, C. A., Villar-Soto, M., Juárez-Rojop, I. E., González-Castro, T. B., Genis-Mendoza, A. D., … & Martinez-Magaña, J. J. (2022). Fluoxetine modulates the pro-inflammatory process of IL-6, IL-1β and TNF-α levels in individuals with depression: a systematic review and meta-analysis. Psychiatry Research, 307, 114317. https://doi.org/10.1016/j.psychres.2021.114317

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in context, 8. https://doi.org/10.7573%2Fdic.212573

Li, X., Hou, Y., Su, Y., Liu, H., Zhang, B., & Fang, S. (2020). Efficacy and tolerability of paroxetine in adults with social anxiety disorder: A meta-analysis of randomized controlled trials. Medicine, 99(14). https://doi.org/10.1097%2FMD.0000000000019573

Shorey, S., Ng, E. D., & Wong, C. H. (2022). The global prevalence of depression and elevated depressive symptoms among adolescents: A systematic review and meta‐analysis. British Journal of Clinical Psychology, 61(2), 287-305. https://doi.org/10.1111/bjc.12333

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Psychiatric notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly Learning Resources. 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 4 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

Learning Resources

Required Readings

Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.

Chapter 28, “Assessing Neurocognitive Disorders (Dementia and Delirium)”

Meditrek

Links to an external site.

https://edu.meditrek.com/Default.html

Note: Use this link to log into Meditrek to report your clinical hours and patient encounters.

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

Chapter 10, “Stimulants and Other Meds for ADHD”

Chapter 13, “Natural Medications in Psychiatry” (pp. 147–148 only)

Chapter 14, “Dementia”

Document: Focused SOAP Note Template

Download Focused SOAP Note Template (Word document)

Document: Focused SOAP Note Exemplar

Download Focused SOAP Note Exemplar (Word document)

Recommended

Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

To Prepare

Review the Kaltura button from the Classroom Support Center (accessed via the Help button) for help creating your self-recorded Kaltura video.

Select an adult patient that you examined during the last 4 weeks who presented with a disorder other than the disorder present in your Week 3 Case Presentation.

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 patient 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.

By Day 7 of Week 7

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:

Click on Start Assignment near the top of the page.

Next, click Text Entry and then click the Embed Kaltura Media button.

Select your recorded video under My Media.

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 7 Assignment 2, Part 2

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